Form 5C-E-245 "Declaration in Support of Request to Proceed in Forma Pauperis" - Hawaii

What Is Form 5C-E-245?

This is a legal form that was released by the Hawaii Circuit Court - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2007;
  • The latest edition provided by the Hawaii Circuit Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form 5C-E-245 by clicking the link below or browse more documents and templates provided by the Hawaii Circuit Court.

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Download Form 5C-E-245 "Declaration in Support of Request to Proceed in Forma Pauperis" - Hawaii

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IN THE
COURT OF THE FIFTH CIRCUIT
STATE OF HAWAI‘I
)
Case no.______________________
)
)
DECLARATION IN SUPPORT OF
)
REQUEST TO PROCEED IN FORMA
Plaintiff(s
)
, )
PAUPERIS
)
vs.
)
)
)
)
Defendant(s)
. )
)
DECLARATION IN SUPPORT OF REQUEST
TO PROCEED IN FORMA PAUPERIS
I,
, am the Plaintiff
___________________________________________________________________________________________________________________
in the above-entitled case. In support of my motion to proceed without being required to prepay fees or
costs or give security therefor, (knowing fully an this does not cover the request or cost for transcripts,
service fees, etc.), I state that because of my poverty, I am unable to pay the costs of said proceedings or
give security therefore; that I believe I am entitled to redress.
I declare that the responses which I have made below are true.
1.
Are you presently employed?
[ ] Yes
[ ] No
a) If the answer is yes, state the amount of your salary per month and give the name and
address of your employer.
b) If the answer is no, state the date of the last employment and the amount of the salary
per month which received.
In accordance with the Americans with Disabilities Act and other applicable state federal laws, if you requre a reasonable
accommodation for a disability, please contact the ADA Coordinator at the Court Administration Office at PHONE NO. 482-2347,
FAX 482-2309, OR TTY 482-2533 at least ten(10) working days prior to your hearing or appointment date.
Reprographics
5C-E-245
(06/07) 5C RevaComm 508 Certified
IN THE
COURT OF THE FIFTH CIRCUIT
STATE OF HAWAI‘I
)
Case no.______________________
)
)
DECLARATION IN SUPPORT OF
)
REQUEST TO PROCEED IN FORMA
Plaintiff(s
)
, )
PAUPERIS
)
vs.
)
)
)
)
Defendant(s)
. )
)
DECLARATION IN SUPPORT OF REQUEST
TO PROCEED IN FORMA PAUPERIS
I,
, am the Plaintiff
___________________________________________________________________________________________________________________
in the above-entitled case. In support of my motion to proceed without being required to prepay fees or
costs or give security therefor, (knowing fully an this does not cover the request or cost for transcripts,
service fees, etc.), I state that because of my poverty, I am unable to pay the costs of said proceedings or
give security therefore; that I believe I am entitled to redress.
I declare that the responses which I have made below are true.
1.
Are you presently employed?
[ ] Yes
[ ] No
a) If the answer is yes, state the amount of your salary per month and give the name and
address of your employer.
b) If the answer is no, state the date of the last employment and the amount of the salary
per month which received.
In accordance with the Americans with Disabilities Act and other applicable state federal laws, if you requre a reasonable
accommodation for a disability, please contact the ADA Coordinator at the Court Administration Office at PHONE NO. 482-2347,
FAX 482-2309, OR TTY 482-2533 at least ten(10) working days prior to your hearing or appointment date.
Reprographics
5C-E-245
(06/07) 5C RevaComm 508 Certified
2.
Have your received within the past twelve months any money from any of the following sources?
a) Business, professional or form of self-employment?
[ ] Yes
[ ] No
b) Rent payment, interest or dividends?
[ ] Yes
[ ] No
c) Pension, annuities or life insurance payment?
[ ] 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 have any cash or do you have money in a checking or savings account?
[ ] Yes
[ ] No (Including any funds in prison account)
If the answer is yes, state the total value owned:
4.
Do you own any 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.
Reprographics
5C-E-245
(06/07) 5C RevaComm 508 Certified
I UNDERSTAND THAT A FALSE STATEMENT OR ANSWER TO ANY QUESTION IN THIS
DECLARATION WILL SUBJECT ME TO PENALTIES FOR PERJURY.
______________________________________________
Plaintiff’s Signature
I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Signed this_____________________________ day of_________________________________ , 2 0_____
______________________________________________
Plaintiff’s Signature
APPROVED AND SO ORDERED:
_________________________________________
JUDGE OF THE ABOVE-ENTITLED COURT
CLEAR FORM
Reprographics
5C-E-245
(06/07) 5C RevaComm 508 Certified
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