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To make prepayment of fees and costs or to give security therefor, and it is my belief that I am entitled to redress, and that I have not, for the purpose of avoiding payment of said cost, divested myself of any property, monies, or any items of value. I. BRIEF STATEMENT OF THE NATURE OF THE ACTION: II. RESIDENCE Affiant s address: (Street) (City) DC 101 (Rev. 1/97) (State) (Zip Code) Page 1 III. MARITAL STATUS: 1. Single Married Separated Divorced 2. If married, spouse s full.

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