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Filing Party’s Name
Filing Party’s Mailing Address
Filing Party’s Telephone Number
IN THE CIRCUIT COURT OF THE _______ CIRCUIT
STATE OF HAWAII
Name(s) of Petitioner(s),
Petitioner(s),
v.
Name(s) of Respondent(s),
Respondent(s).
Special Proceeding No.
DECLARATION IN SUPPORT OF REQUEST
TO PROCEED IN FORMA PAUPERIS FOR
MORTGAGE FORECLOSURE
CONVERSION PETITION
DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS
FOR MORTGAGE FORECLOSURE CONVERSION PETITION
I, , declare that I am the petitioner in the above-entitled case; that
in support of my petition to proceed without being required to prepay fees, costs or give security
therefor, I state that because of my poverty, I am unable to pay the costs of said proceeding or to give
security therefor; that I believe I am entitled to relief.
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1. Are you presently employed? Yes No
a. If the answer is “yes,” state the amount of your salary or wages per month, and give the
name and address of your employer.
b. If the answer is “no,” state the date of last employment and the amount of the salary and
wages per month which you received.
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2. Have you received within the past twelve months any money from any of the following sources?
a. Business, profession or form of self-employment?
Yes ____ No ____
b. Rent payments, interest or dividends?
Yes ____ No ____
c. Pensions, annuities or life insurance payments?
Yes ____ No ____
d. Gifts or inheritances?
Yes ____ No ____
e. Any other sources?
Yes ____ No ____
If the answer to any of the above is “yes,” describe each source of money and state the
amount received from each during the past twelve months.
3. Do you own any cash, or do you have money in a checking or savings account? (Include any
funds in prison accounts.)
Yes ____ No ____
If the answer is “yes,” state the total value of the items owned.
4. Do you own real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding
ordinary household furnishings and clothing)?
Yes ____ No ____
If the answer is “yes,” describe the property and state its approximate value.
5. List the persons who are dependent upon you for support, state your relationship to those
persons, and indicate how much you contribute toward their support.
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I declare under penalty of perjury that the foregoing is true and correct.
Executed on _________________________________________________________________
Date
Signature of Petitioner
APPROVED AND SO ORDERED:
Judge of the Above-Entitled Court
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