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Form B – Request to Proceed without Paying Filing Fees

May 11, 2021 | Criminal Procedure, Hawaii

_________________________________________________

[Insert appropriate court]

_____________________________

(Petitioner)

v.

_____________________________

State of Hawai’i

DECLARATION IN SUPPORT

OF REQUEST TO PROCEED

WITHOUT PAYING FILING FEES

I, __________________________, declare that I am the petitioner in the above entitled case. I ask to proceed without paying filing fees. In support of my request, I state that, because of my poverty, I am unable to pay the filing fees and that I believe I am entitled to relief.

1. Are you presently employed?

Yes ______ No ______

a. If the answer is “yes,” state the amount of your salary or wages per month, and give the name and address of your employer.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

b. If the answer is “no,” state the date of last employment and the amount of the salary or wages per month that you received.

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

2. Have you received within the past twelve months any money from any of the following sources?

a. Business, profession or other employment?

Yes ______ No ______

b. Rent payments, interest or dividends?

Yes ______ No ______

c. Pensions, annuities or life insurance payments?

Yes ______ No ______

d. Gifts or inheritances?

Yes ______ No ______

e. Any other sources?

Yes ______ No ______

3. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison accounts.)

Yes ______ No ______

If the answer is “yes,” state the total value of the items owned.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Do you own real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)?

Yes ______ No ______

If the answer is “yes,” describe the property and state its approximate value.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Signed on .

(date)

________________________________________

Signature of Petitioner

CERTIFICATE

I hereby certify that the petitioner herein has the sum of $_______ on account to his/her credit at the _________________________________________________________________________________ institution where he/she is confined. I further certify that petitioner likewise has the following securities to his/her credit according to the records of said institution __________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________

Authorized Officer of Institution

Added May 11, 1995, effective May 11, 1995; further amended September 6, 2005, effective January 1, 2006.