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Fill and Sign the North Carolina Sue Form

Fill and Sign the North Carolina Sue Form

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Open the document and fill out all its fields.
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Plaintiff      VERSUS Defendant Title Of Person Authorized To Administer Oaths Date Commission Expires SEAL Food stamps. Aid to Families With Dependent Children (AFDC). Supplemental Security Income (SSI).             I am presently a recipient of I am represented by a legal services organization that has as its primary purpose the furnishing of legal I am a prison inmate. A Department of Corrections report is attached showing deposits, withdrawals, and Although I am not a recipient of food stamps, AFDC, or SSI, nor am I represented by legal services, I am                                                 the applicant is authorized to bring suit as indigent. the petition is denied.       Commissioner Executive Secretary Deputy Commissioner STATE OF NORTH CAROLINA North Carolina Industrial Commission 430 N. Salisbury Street Raleigh, NC 27611 T File No. PETITION TO SUE AS AN INDIGENT G.S. 1-110 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 Industrial Commission. Therefore, I now petition the 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) services to indigent persons, or I am represented by private counsel working on behalf of such a legal services organization- (Attach a letter from your legal services attorney or have your attorney sign the certificate below.) balances in my prison trust account during the last six months. financially unable to advance the costs of filing this action or appeal. SWORN AND SUBSCRIBED TO BEFORE ME Date Date Signature Signature of Applicant Name And Address (Type or Print) CERTIFICATE OF LEGAL SERVICES/PRO BONO REPRESENTATION I certify that the above-named applicant is represented by a legal services organization that has as its primary purpose the furnishing of legal services to indigent persons or is represented by private counsel working on behalf or under the auspices of such legal services organization. Date Signature Name And Address (Type Or Print) ORDER Based on the Affidavit appearing above, it is ORDERED that: Date Signature (Unofficial form)

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