State of North Carolina
|State of North Carolina | | |
|North Carolina Industrial Commission | | |
|Petition to Appeal as an Indigent Person |IC File # | |
| | | |
| | | |
|Plaintiff's Name | |Defendant's Name |
| | | |
|Address | |Address |
| | | | |
| City | State | | City State |
| |Zip | |Zip |
| |AFFIDAVIT | |
|As the individual plaintiff in the above-entitled action, I affirm that I am financially unable to advance the required costs for the prosecution of this action|
|before the North Carolina Court of Appeals. Therefore, I now petition the Industrial Commission for an order allowing me to bring suit in this action as an |
|indigent. |
|Check one or more of the boxes below as applicable |
| |
|( I am presently a recipient of |
|( Food Stamps |
|( Aid to Families With Dependent Children (AFDC). |
|( Supplemental Security Income (SSI) |
| |
|( I am a prison inmate. A Department of Corrections report is attached showing deposits, withdrawals, and balances in my prison trust account during the|
|last six months. |
| |
|( Although I am not a recipient of food stamps, AFDC, or SSI, I am financially unable to advance the costs of filing this action or appeal. |
| Sworn and subscribed to before me | | |
| | | |
| | | |
| Signature | | Name of Applicant (Please Print) |
|Date | | |
| | | |
| | | |
| Title of Person Authorized to Administer Oaths | | Signature of Applicant |
| | |Date |
| | | |
|SEAL | | |
| Date Commission Expires | | |
| |ORDER | |
| Based upon the Affidavit appearing above, it is ORDERED that: |
|( The applicant is authorized to bring suit as an indigent |
|( The petition is denied. |
| |( Commissioner ( Deputy Commissioner |
| |( Executive Secretary |
| Signature Date | |
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