Fill and Sign the Request to File a Case or Make an Appeal as an Indigent Form

State of North Carolina North Carolina Industrial Commission TA- P ETITION TO SUE AS AN INDIGENT PERSON IC File # v. Plaintiff's Name Defendant's Name 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 Industrial Commission. Therefore, I now petition the Industrial Commission for an order allowin g me to brin g suit in this action as an indi gent. 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. (An affidavit lis ting my income and expenses is attached) Sworn and subscribed to before me Signature Date Name of Applicant (Please Print) Title of Person Authorized to Administer Oaths SEAL Signature of Applicant Date Commission Expires Date ORDER Pursuant to N.C.G.S. § 1-110 and 4 NCAC 10B .0103, the undersigned has determined t hat this action is not frivolous. 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 Si gnature Date E-mail Affidavit to: dockets@ic.nc.gov OR Mail Affidavit to: N.C. Industrial Commission Docket Section 1236 Mail Service Center Raleigh, NC 27699-1236