Haw. R. Penal P. Form B

_________________________________________________

[Insert appropriate court]

____________________________ (Petitioner) vs. ____________________________ State of Hawaiʻi 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 ______

If the answer to any of the above is “yes,” describe each source of money and state the amount received from each during the past twelve months.

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