20190802Mendez Fee Waiver - Redacted.pdf

Full Name of Party Filing Document
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RECE,VED
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Mailing Address (Street or Post Office Box)
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City, State anO Zip CoOe/
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Telephone
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BEFORE THE IDAHO PUBLIC UTILITIES COMMISSION
Email Address (if any)
ln the Matter Of:
An, L w\frNDeL Case No. INT- ea' lq-o3
MOTION AND AFFIDAVIT FOR FEE
WAIVERAlletr^u\ l&,rqltqi
VJ
vN ,/t\Ov / a[^',G to start or defend this case without paying
fees, ldaho Code Section 31-3220, and certify:
l. This is an action for ltype of case)A0PEat
2. I am unable to pay the court costs. I verify that the statements made in this Affidavit are true
and correct. I understand that a false statement in this Affidavit is perjury and I could be
sent to prison for one to 14 years. The waiver of payment does not prevent the court from
later ordering me to pay costs and fees.
3. I am unable to pay the costs for assembling the administrative record.
(Do not leave any items blank. lf any item does not apply, write "N/A". Attach additional pages if more space is
needed for any response.)
IDENT!FICATION AND RESIDENCE:
Name:/Anv U /v\e^r p€ L Other name(s) I have used
Address:Z1l?. N GrrVnauaue w*\/u"4Dtap , LV)
a71Q5
Phone
PAGE 1
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How long at that aooressz4?tlE4'9 P\n CF
7
La-r) (G"- 6ej I
MOTION AND AFFIDAVIT FOR FEE WAIVER
cAo FW 1-9 07t01t2016
Year and place of birth !aDcI\LL S,*f vaQct
Education completed (years): f'liGfl CCtuo,L I 5o r"n GLcEGL
FAMILY:
Marital StatusftnOle I Married I Divorced IWidowed ! Separated
The following minor children live with me:
Name (use initials only) Age Relationship Child Support Received ($/monthl
EMPLOYMENT:
Occupation c*Llet lt<x Employed by:Ston CwavivG
t( \ t Salary:s 0ePr*rv2
Position
1l
cN Prusec\ SiZL
or $_ per hour
your current position is temporary what are theMonthly gross income
start and end dates?See A9.rr* oltug 2*v Sruf
4
Phone number to use to verify 2.6 lf you have held this job less than
one year, previous employer
Phone number to use to verify:
Spouse's Occupation Employed by:
Position: Salary: $or $_ per hour
Monthly gross income lf your spouse's current position is
temporary what are the start and end dates?
I receive assistance or support from the following sources and in the following monthly amounts
Spouse s Welfare s Food Stamps: $_Relatives:s
Unernployment Compensation s Retirement: $_
Former Spouse: $_ other
MOTION AND AFFIDAVIT FOR FEE WAIVER
cAo FW 1-9 07t01t2016
Social Security:
$
PAGE 2
s
lf unemployed, how long since your last regular employment?
List all places where you have applied for work in the last six months
Company Last Applied
L r"l PL"'1 LD
Reason for Rejection
Are you willing to work now? _ What work can you do?
WhatistheminimumWageforwhichyouarewillingtowork?$
List all employers you worked for during the last three years.
Company Date Terminated Ending Salary Reason for Termination
L q )"1 hto ftt*ut)
NAE CtA }U a cl 6viY
Ant v C-/\pLt€)c wcrrl( s; (E
Are you capable of working ,o*r("s ! No lf no, why not?
lf a health problem keeps you from working, provide the name of your treating doctor:
ls your health problem permanent? [ Yes E No
When will you be released to work?
MOTION AND AFFIDAVIT FOR FEE WAIVER
cAo FW 1-9 07t01t2016
PAGE 3
ASSETS:
List all real property (land and buildings) owned or being purchased by you.
Address City State
Wo >I
Legal
Description
,+I;L9
Value
1o1 \vql"RA(; L
[rEX. t C) uGCJ,t tlc tt I
Your
Equity
Value
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List all other property owned by you and state its value.
Description (provide description for each item)
Veh inlac Nri s ou FRo,'\i trA )-*o
BanUCredit Union/Savings/Checking Accounts Lve&
Stocks/Bonds/lnvestments/CertificatesofDeposit
Trust Funds
Retirement Accou nts/l RAs/40 1 (k)s
Cash Value lnsurance
ltlotorcycles/Boats/RVs/Snowmobiles
Furniture/Appli ances A-f v
Jewelry/Antiq ues/Collecti bles
3v +
rI
|r/cl r"a,E-
TVs/Stereos/Com puters/Electron rnQ
Tools/Equipm
Sporting Goods/Guns
Ho rses/L ivestock/Tack
Other (describe
\ER
MOTION AND AFFIDAVIT FOR FEE WAIVER
cAo FW 1-9 07t}1t2016
PAGE 4
Notes and Receivable
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EXPENSES: (List all of your monthly expenses.)
Expense
RenUHouse Payment
Vehicle Payment(s)
Credit Cards (List last 4 digits of each account number.)
Average
Monthly Payment
C-lrrr,
Loans (name of lender and reason for loan)
Electricity/N atural Gas n-lrWater/Sewerff
Phon e
Cellular Phone
Cable/Satellite TV/l nternet
Groceries
Dining O
Clothi
Auto Fuel/Transportation
Auto Maintenance
Cosmetics/Ha i rcuts/Sa
E ntertainmenUBooks/Ma g azines
Horne lnsurance
Auto lnsurance
Life
MOTION AND AFFIDAVIT FOR FEE WAIVER
cAo FW 1-9 07t01t2016
Fq^-i tY P\^^lif
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PAGE 5
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lncr rranno
Average
Monthly PaymentExpense (continued)
Medical lnsuran .A
Medical Expense
Child Care
Other (describe)
When did you file your last income tax return? AO l1 Amount of refund: $rllt
PERSONAL REFERENCES: Ohese persons must be able to verify information provided.)
Name Address Phone Years Known
C w tt I NJ Go\cAi AJ c -(rt--1?)-
CERTIFICATION UNDER PENALTY OF PERJURY
I certify under penalty of perjury pursuant to the law of the State of ldaho that the foregoing is
true and correct.
Date:8 le lt1
Anv t lf\tr^t r)E- 7
Typed/printed Signature
MOTION AND AFFIDAVIT FOR FEE WAIVER
cAo FW 1-9 07t01t2016
PAGE 6
MTSCELLANEOUS:
How much can you borrow? $ /vo\ S v Q€ From whom I /hc*pen I 5 icrfr-\
Eamings and Hours Oty Rale Curent YTDArnourn
Employee Salary
Federal
So<ial Security Employee
iiledicare Employee
lD - Wi$holding
Net Pay
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