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ri,{r.." UNITED
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STATES DISTRICT

for the Eastern District of Missouri

:::,!.$tr;l#l il;sh":frt o{ tr.4*

On

the

Relations of Michael

(lncarcerated)
Petitioner

Fullilove

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Vs.

Case No.

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lass4effrey Carson
respondent

Da

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Petition writ of HABEAS CORPUS

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Standing At Law SF 181 Michael Fullilove is white and American lndian Sf L81http://www.scibd.comfdocument/323211542lMarshawn-SF-181-0160905-0001
petitioner his sent his Statutory Declaration register mait to Governor Jay Nixon who is the chief
Magistrate of the STATE of MISSOURI Defendant Michael Fullilove has a personal treaty with
the Governor Jay Nixon of MISSOURI via

http://www,scibd.comldocument/3286578L5/Marshawn-statutory-declartion-upload2016123-0001pdf
Petitioner is being restrained of his Liberty and being deprived of his Rights and is being
unlawfully imprisoned in ST.LOUIS MSI/WORKHOUSE in the STATE of MISSOURI vislations of
United Nations dectaration on Human rights Article 11. Everyone charged with a penaloffence
has the right to be presumed innocent until proved guilty according to the law in a public trial
at which his has all the guarantees necessary for his defense
BOI\D Definition - A certificate or evidence of a debt... Defendant was forcefully assimilated
and Theft of intellectual property was done by the agents with Theft of identity forcing him to
pay back a debt that he never knew about and never got his free prior informed consent
The cause of the restraint according to the best knowledge and belief of petitioner is set forth:

petitioner restraint in the CITY JAIL is by order of a MUNIPAL COURT JUDGE on alleged
CRIM1NAL CHARGES of Felony C RSMO 571.070 Felony D RSMO 575.150 Felony C RSMO
L95.2AZ Misderneanor A RSMO L95.233
An court cannot acquire Jurisdiction to try someone for an act made criminal only by an
unconstitutional law and thus an Offense created by an unconstitutionalSTATUTE is no

longer a crime and a conviction under such STATUTE cannot be a legal cause for
irnprisonment State V Benzel 583 N.Ur. 2d 434 220 Wis 2d 588 (19981

ln every crimina! trial the prosecution must prove the Corpus Delicti or the body of the crime
itself i.e the facts of injury, loss or harm and the existence of a criminal agency as its cause
people V sapp73 p.3d 433.467 (cal2003l [quoting people V.AlVarez (2002] 27 cal4th 1151
11681169 119 cal.rptr 2d 903. a5 p.3d 3721
Petitioner made a special appearance to the court on 4-11-14 POLICE arrested him they said he
had a warrant Defendant ask to see the warrant they never presented the warrant. Defendant
was being falsely imprisoned for 5 month then with Excessive bond He was never promptly
taken before a Judge They process him though the systern forced assimilation violations of his
lndigenous rights Article I Individuals have the right not to be subjected to any kind of forced
assimilation or destruction of their culture
Defendant never got a f$r Trial
Petitioner He was denied a preliminary hearing on several occasions never had a preliminary
hearing Where a court failed to observe safeguards it amounts to denial of due process of
Law court is deprived of Juris Meritt V Hunter. C.A Kansas l7OFZd739
Petitioner is unlawfully being held in the ST.LOUIS Clfi MSIIWORKHOUSE for 3 months now
since September 27,2At6 POLICE came to the home No warrant was served and he has not
been brought before a Judge to determine the lawfulness of this incarceration
Petitioner is report very ill his Health is deteriorating needs to see a doctor his is bleeding for
his rectum can't hold any food down he has no energy needs nTedical attentisn petitioner has
been DElttlED rnedical attention these are violations of his lndigenous Rights
Petitioner says Judge Threats to revoke the bond...Judge took an OATH to protect the rights of
the people
Unlawfulsearch and seizure (MISSOURI RSMO 542-030) Warrant was computer originated and
are NOT sign by a Judge No affidavit there was No name on the warrant they use EXCESSIVE
force The POLICE violating his rights on covenant on civil and political rights Article 17. No one
shall be subjected to arbitrary or unlawful interference with his privacy family home or
correspondence nor to unlawfut attacks on his honor and reputation

United states supreme court... stress the need for'individualized review to avoid the issuance
of rubber stamp warrants state VS Paulick 277 Minn. 140 151 N.W 2d 596 (1967)

the beginning does not become valid by lapse of time 15.&

Law Blaclds Law Dictionarygth Ed. Pg 1856

A thing void in

d,

R. 58 maxirns

of

Things invalid from the beginning cannot be made valid by subsequent act Trayner Max 482
Maxims of Law Btack's Law Dictionary gth Ed. pg 1862
NO freeman shall be seized or imprisoned or stripped of his rights or possessions or outlawed

or exiled or deprived of his standing in any other way nor will we proceed with force against
him or send others to do so except by the laurful Judgment of his equal or by the law of the
land Magna Carta 1215
Mc NABB DOCTRINE Evidence obtained during an illegal detention that is one which the
prisoner has not been promptly taken before a committing magistrate as required by law is
inadmissible in a criminal trial Mc. Nabb V. united states, 318 U.S 332,63 S Ct.608 87 L Ed 819,
(1e431

lllegal arrest is a assault and battery the person so attempted to be restrained of his Liberty
has the same rights and only the same rights to use force in defending himself as he would
have in repelling any other assault and battery State VS Robinso n 72 A 2b 26A (19501
A warrant is regarded as insufficient and thus VOID if on its face it fails to state facts sufficient
constitute a crime Wharton's Crim. Proc., 12th Ed.,Vol.1,p.15Z(1g74)

Petitioners right The lnternational covenant on civil and political Article 9. L. Everyone has the
right to liberty and security of person. No one shall be subjected to arbitrary arrest or
detention. No one shall be deprived of his liberty except on such grounds and in accordance
with such procedure as are established by law. 2. Anyone who is arrested shall be informed, at
the time of arrest, of the reasons for his arrest and shall be promptly informed of any charges
against him. 3. Anyone arrested or detained on a criminal charge shall be brought promptly
before a judge or other officer authorized by law to exercise judicial power and shall be entitled
to trial within a reasonable time or to release. lt shall not be the general rule that persons
awaiting trial shall be detained in custody, but release may be subject to guarantees to appear
for trial, at any other stage of the judicial proceedings, and, should occasion arise, for execution
of the judgment. Article 1-27
The Congressional records page 43220 Congress is no bound by its constitutional system of
delegated powers lts only test is under the obligatory power to promote Human Rights in these
five fields of endeavor Civil political Economic Social and Cultural these are found in article 55
and 56 of the charter of the United States Any judge deciding on the validity of Legislation must
have two books before him one the constitution of the United-states and two the Charter of
the united f a.tions lf he does not find Authority for the Act in the constitution he will find it in
the charter. The authority was not found in the constitution Source congressional record page
A3220 statement By Carl B Rix President of the American Bar Association May 11 L955.. The
United Nations 2nd decade on the People of African descent programs of activities Justice
Recognition and development
Presidential Executive orders t3LO7 lmplementation of human rights treaties

Pope Francis peace No more slaves brothers and sisters

House joint Resolution 194-Acknowlede that slavery is incompatible with the basic founding
principles recognized in the Declaration of lndependence that all men are created equal
pope Frarrcis-Motu Proprio 2013 on the Jurisdiction of Judicial Authorities of Vatican state on

criminal matter
Pope's Apology to Indigenous Peoples

Redress for the Petitioner

For these Causes Petitioner wants to know why the Judge is depriving hirn of his rights and
liberty. Petitioner suggests that this Lawful Court Grant the writ of Habeas Corpus and that he
be immediatety discharged from this imprisonment respectfully. Petitioner is not a flight risk

and should be released on his own recognizance/needs to see a doctor/dismiss the case/justice
Fetitioner needs A Fear Hearing/Petitioner needs A new Judge
AFFTRMATON OF PETITION BY PETITIONER'S NEXTOF FRIEND

now knounas priya Sha ul me el consort on the behalf of the petitioner in and for
the above and foregoing petition For a Writ of HABEAS COPUS because of obstruction of mail in
the ST.LOUIS CITY JUSTTCE/MSI By the respondent do hereby attest and affirm under the pains
and penalty of perjury per 28 uscL746 that the above and forgoing statements are true and
correct as I verily believe to the best of my ability
I Sionya Haley

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Affirmed to and subscribed before

metnis&Qday of December 2016

4Y rql['lqhts

N*Asorrduce tdentification

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Defendant says The punishments especially has been taking over time after time 3 YEARS now
constitute cruel unusual punishment To imprison someone time after tirne which he struggling
to make ends meet for inability to post a BOND is cruel and unusual punishment

Michael Fullilove now known as Marshawn Sha ul rne el a white and Native American of Cuban
ancestry The patriarch of the Ani-yu-Wiya Tribe of Cherokee Moors was assault and kidnap at
comes after Michael was brutatly attack by Police ST.LOUIS just 6 days Prior to where he
pacifically express the facts that he was not of BLACK or African American race as was his
assailant shortly before he was falsely imprison deprived of his Liberties and robbed of his
subsistence

If States shall provide redress through effective mechanisms which may include
restitution developed in conjunction with Indigenous peoples with respect to their cultural
Intellectual ,religious and spiritual propefi taken without their free prior and informed consent
or in violation of laws traditions and customs.

Afiicle

t. All persons shall be equal before the courts and tribunals. In the determination of
any criminal charge against him, or of his rights and obligations in a suit at law, everyone shall
be entitled to a fair and public hearing by a competent, independent and impartial tribunal
established by law. The press and the public may be excluded from all or part of a trial for
reasons of morals, public order (ordre public) or national security in a democratic society, or
when the interest of the private lives of the parties so requires, or to the extent strictly
necessary in the opinion of the court in special circumstances where publicity would prejudice the
interests of justice; but any judgement rendered in a criminal case or in a suit at law shall be
made public except where the interest of juvenile persons otherwise requires or the proceedings
concern matrimonial disputes or the guardianship of children.

Article 14

2. Everyone charged with a criminal offence shall have the right to be presumed innocent until
proved guilty according to law.
3. In the determination of any criminal charge against him, everyone shall be entitled to the
following minimum guarantees, in full equality: (a) To be informed promptly and in detail in a
language which he understands of the nature and cause of the charge against him;
(b) To have adequate time and facilities for the preparation of his defence and to communicate
with counsel of his own choosing;
(c) To be tried without undue delay;

(d) To be tried in his presence, and to defend himself in person or through legal assistance of his
own choosing; to be informed, if he does not have legal assistance, of this right; and to have
legal assistance assigned to him, in any case where the interests of justice so require, and
without payment by him in any such case if he does not have sufficient means to pay for it;
(e) To examine, or have examined, the witnesses against him and to obtain the attendance and
examination of witnesses on his behalf under the same conditions as witnesses against him;

(f) To have the free assistance of an interpreter if he cannot understand or speak the language
used in courfi

t{\{\

(g) Not to be compelled to testify against himself or to confess guilt.

4. In the case of juvenile persons, the procedure shall be such as will take account of their age
and the desirability of promoting their rehabilitation.
5. Everyone convicted of a crime shall have the right to his conviction and sentence being
reviewed by a higher tribunal according to law.
6. When a person has by a final decision been convicted of a criminal offence and when
subsequently his conviction has been reversed or he has been pardoned on the ground that a
new or newly discovered fact shows conclusively that there has been a miscarriage of justice, the
person who has suffered punishment as a result of such conviction shall be compensated
according to law, unless it is proved that the non-disclosure of the unknown fact in time is wholly
or partly attributable to him.
7. No one shall be liable to be tried or punished again for an offence for which he has already
been finally convicted or acquitted in accordance with the law and penal procedure of each
country.

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U.S. Office of Personnel Management

Guide to Personnel Data Standards

ETH NICITY AND R.ACE IDENTIFICATION

(Ptease read the Privacy Act Statement and instructions before completing form.)

Name (Last, First, Middle lnitial)

Social Security Number

Birthdate (Month and Year)

FULLILOVE,MICHAEL,A

48$76*

oa1g76

Agency Use Only

Privacy Act Statement

Ethnicity and race information is requested under the authority of 42 U.S.C. Section 2000e-16 and in compliance
with the Office of Management and Budget's 1997 Revisions to the Standards for the Classification of Federal
Data on Race and Ethnicity. Providing this information is voluntary and has no impact on your employment
status, but in the instance of missing information, your employing agency will attempt to ldentify your race and
ethnicity by visual observation.

This informaiion is used as necessary to plan for equal employment opportunity throughout the Federal
government. lt is also used by the U.S. Office of Personnel Management or employing agency maintaining the
remrds to locate individuals for personnel research or survey response and in the production of summary
descriptive statistics and analytical studies in support of the function for which the records are collected and
maintained, or for related workforce studies.
Social Security Number (SSN) is requested under the authority of Executive Order 9397, which requires SSN be
used for the purpose of uniform, orderly administration of personnel records. Providing this information is
voluntary and failure to do so will have no effect on your employment status. lf SSN is not provided, however,
other agency sources may be used to obtain it.
Specific lnstructions; The two questions below are designed to identi{y your ethnicity and race. Regardless of your answer to
1, go to question 2.

question

Question 1. Are You Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.)

ffives

Xno

Question 2. Please select the racial category or categories with which you most dosely identify by placing an
box. Check as many as apply.

RACIAL CATEGORY

American lndian or Alaska Native

in the appropriate

DEFINITION OF CATEGORY

(Check as many as apply)

ffi

X"

A person having origins in any of the original peoples of North and South America
(induding Central America), and who maintains tribal affiliation or community
attachment.

nRsiun

A person having origins in any of the original peoges of the Far East, Southeast
Asia, or the lndian subcontinent including, for example, Cambodia, China, lndia,
Japan, Korea, Malaysia, Pakistan, the Philippine lslands. Thailand, and Vietnam.

I
fl

eAct orAfrican American

A person having origins in any of the black racial groups of Africa.

ttatiue Hawaiian orOther Pacific lslander

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific Islands.

ffi

wr'it"

A person having origlns in any of the original peoples of Europe, the Middle East, or
North Atica.
Standard Forrn 1Bl
Revised August 2005
Frevious editions not uqable
42 U.S.C. Section 20006-16
NSN 7540-01-099-3446

Statutpry-Deqlaration
In the matter Amendment of Missouri Heath Division of vital records Regisrration # 124-76-001818
I, Michael Anthony trullilove now known as: Marshawn Shitoh Wijaya Sha ' ul me ' el c/o 3915 N
Florissant St.Louis Missouri do solernnly declare in accord wjth: the 1931 statute of Westminster
(nttp:llwww.Oetaxc , 1778 Articles of confederation and perpetuai Union Articles XI, 1812
Treaty of Ghent; 1794lay Treaty; i836 Treaty of Marrakesh (Morocco) all recognized and valid
treaties, constitution for the united states of Americ4 the 1948 Charter of the United Nations, the
1975 Inter-American Declaration on the rights of Indigenous Peoples and the United Nations 2d
decade of the world's Indigenous people, that irpon discovering that the registration of a Live Birth
of February Sh t916, in the STAIE Of"VTTSSOURVMISSOIIRI REPTIBLIC catled Missouri
Republic was a contract between my mother and the U.S. Govemment Corporation who did not tell
her she was selling me, a flesh and blood child, to the STAIE OF MISSOURI CORPORATTON as
the Chattel Properry/Slave which is a violation of Human Rights, I hereby void the conrract, at)
initio for fraud. Since I am a F]esh Ald Blood: Melaninite Cherokee Native American Moor of
Turtle Isiand and of this Planet in accord with the United Nations Declaration on the Rights of
Indigenous Peoples, HJR 194- trttp://govtrack.uslcongress/billsll10/hres194ltext U.S -ongress
Apology to African Americans for Slavery, S, Con, Res. 26- United State Senate Apology to Af.i"u,
Americans for Slavery; u.s. apology To Native Americans (Sec 81 13 of H.R.3 326 Depi*ment of
Defense Appropriations Act) http://ivww.&ovtrack.us./conEress/billsi i l1lhl3326ltext .. Upon
discovering that Elizabeth Alexandra Mary Windsor Mountbatten Baffenberg
[MISNOtvfgR: eueen
Elizabeth nl violated her coronation oath ( a legal1y binding contract) of June Z"d 1953. On May 14,
2Ol1 at Southward Crown Court (1 English Grounds in Southward, London, England) Defendanr:
John Anthony Hill in the United Kingdom proved before an English jury rhar Elizabeth
Aiexandra
Mary Windsor-Mountbatten, was not the rightfut monarch and neveiwis: queen! Elizabeth is not
the rightful monarch and never was. This was a two point argument. Firstly, Elizabeth
knew- then
and now- that she was crowned on a fake coronation stone instead of the real Stone
of
Destiny/Coronation Stone, which meant not only was she never properly crowned,
but she
knowingly and fraudulently was conning the Public and that is why she did not want her coronation
televised. RBGINA v.JAH (case Ref. Numtrer:T20101746) (See
httQ;/zslwrv.mtriai.ory'node/133). r declare that rhe name MICIIAELANTHoNY
FULLILOYE
on the registration of the Live birth is a corporation and Michael Anthony Fullilove,
is an
Indigenous, Fiesh & Blood lvlan. I am Not a corporation, artificial p".roo, natural person,
fictitious
entity or vessel of the United States as defined under 18 U.S.C. 9 and I give noticalnternationally,
Domestically and Universa{ly via this Declaration that I deny corporate existence.
Under
reservation of All My Rights Unalienable and otherwise, I am: IndigenouslAutochthon
of this
planet. And I make this solemn declaration conscientiously believing it
to be true, ano t<nowing ttrat
this is the same force and effect as made under oath.

Jurat
united Nations Declaration on the right of Indigenous peoplesUnited Nati
Unired
Nations Convention on
Economic, social
,crat d.
& culrural
cultural Rights,
Krghts, united
United Nations charter; Aaicle
aaicle 55 &
&:56, presidential
proclamation 7500,H.J.R. 194, S. Con. Res. 26 S. 1200, HJR_3

Affirmed to and subscribed before

methi&day

of

May_20
By:
Affianr UCC 1j308 wirhout prejidice

77 a /f25, 6
My Commissioner Expires

...u1tttlll llliltlrr,.

*o':\

r+atfr$i;+r.

*_-"-r_\oft*:m:eqo+;:2
se*t l*?

-s'c-, ";{graRv

=q:.*q@'=a!l-:

Statutorv Claim in aecord with IRS MAUNAL 21.7.13,3.2.2f2)/1707 Cestui Oue Yie Trust Act
I, Michael Anthony Fullilove now known as: Marsharvn Shiloh Wijaya Sha'ul me ' el, Indigenous
in Accord with: tlae
Autochtonous Flesh and Blood Man (Cherokee) Moor), Claim
United Nations Declaration on the Rights of Indigenous Peoples,
42
http:/livww.un.ore/Docs/iqt{Bai&Eplws.asp?m=A1RESl661
http://rvww.un.orglesa/sqgiev/untii/documents/DRlPSen.pdf Constitution of the At-Sik-hata:
Nation of Yamassee-Moom: http:/lw:vw.sqribd.csn{doc/59269-37jYCon-stitition Presidentiatr
Proclamation ?500; HIR-194 - http:1/wr.r,vtgt:o.egv1fdsys/pkglBILLS-1l0hres l94eUpggBJLLlSi. 0hres 1 94eh. pdf; S. Com. Res- 26 - http:/&vwp,. gpo. gov/fdsys/pk g/B ILLS1 1 t sconrgs26es./pSlflBlll-S- I 1 l sconresZ6es&df ; HJR- 3 - ; 197 5 Inter-American Declaration on
the Rights of Indigenous Peoples; 2 stat.153, Title 8 USC 876, IR.S Mission Statement
http://wwiv.irs.gov/nub/irs-news'ir-98-59.pdf , that I am not a decedent (IRS Manual
21-7-13.3.2.2/)-1am alive and I am not dead (1540 Cestuti Que Vie Act,17O'] Cestui QueYie
Trust Act htts://www. lesislation. gov.uk/:Ipeb/Annl6l72).
1

I want the record held in your computer database which my list rne as deceased to be changed to
alive. According to IRS MANU ALZL.I -13.3-2.2(2): An inf.ant in the decedent of an estate or
grantor. owner or trustor of a trust. guardianship. receivership or custodianship. that has .vet to
receive an SSN: http:/lirs.gov/inn/21ljrm. 2i-007-013r.htrni. Declaration of assumptive deathis a
ficfion: G.R. No.160258 Repubfic of The Philippines v. Gloria Bermudez- Lorino:
http://ca.iudiciary.gor,.ph/index.p_hp?action=rnnuactual contents&api70100&p=y - IhaveaSSN
Number, so by the IRS MANU AL:21.7 -13-3.2.2(2),I am not a decedenl @lack's Law Dictionary
8'h Ed., p. 435 - decedent n. Adead person, esp. one who has died recently). I am no longer liable
for: a) Maritime Liens being enforced against me, b) securities being taken out of the estate. All
Maritime Liens currently being enforced against me I hereby claim invalid, null & void, ab inito pro tunc. See: Lieber code-Art 3,31,33,38: http:1/avalon.law.val@
and
Art. 45, 46, &.55 of Hague Conveniion fV Oct. 18, 1907 http://.,i,wrv.icrc.orelih1.nsf/FUll*1195.

am the infant who does have a SSN Number 489-76-3195 which makes me the beneficiary of this
trust. The SSN 489-76-3195 and the name&ests within me: an Indigenous Autoch&onous n-iving
Man- Being that the IRS works in Admkalry, the IRS according to its own codes, can no longer

enfolceanymaritimeLiensagainstmyself,asIhavenowc]aimedffi:Iamnot1oslat*..
sea, nor am I a decedenr/ vessel in commerce (i8 USC g) (1707 Cestui Que VieAct, U.K)$ffi q|r"}l15
.Iurat
United Nation Declaration on the rights of Indigenous Peopleshttp://www.un. olg/esa/socder,/unpfii/documents/I)RiPS en. pdf
UN Declaration on the Rights of Indigenous Peoples, {lN Convention on Economic, Social &
Cultural Rights, United Nations Charter; Articles 55 & 56; Congressional Record P. A322A may 11
1955, Motu Proprio July 2013, Pope Francis Apology to the Indigenous Peoples & World Day of
Peace Lettet IDFPAD, Presidential Proclamation 7500, H.J.R. 194, HJR- 3, S. Con. Res 26

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By:
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D[i g g a*l$
{.i.s. District

DISTRT.T couR'r
UNI:tED
DISTRICT OF MISSOURI
EASTERN'TATES

Coufi

M0
lrdi$tue\

Eastern Distrist of

Ful\,laue- , I

)
)
)
)
)

Plaintiff(s),

No.

Defendant(s).

MOTION TO PROC,EED IN FOR.MA PAUPERIS

proceed in
, herebv applv for leave to

r, lnifChng[ Fultikxi e,

and without giving security therefor' In support

this action without prepayment of fees or costs
are true:
of this application, I declare that the following facts

(l)

to relief'
I am the plaintiffin this case and I believe I am entitled

the costs of this

Because of my poverty I amunable to prepay
proceeding or to give security therefor'

(2)

(3)Thenatureofmyaction,defense,orappealisbrieflystatedas
follows:

is true and correct' Executed on

I declare under penalty of perjury that the foregoing

beCerqbe(

,201{a

-i

Signature of Plaintiff

",lll

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opracrsrn4re

-SI*DISTRICT

aPPEatSCOURtot

Orr{En PeNfL (SPecilbelow)

TION NUMBER

tl4rt\rqe\ Fuiiltlie vs 1rrlule 0it&*/

ffi

It:
l:.

CFIARCE/OFFENSE (doscnbe rf appLmbte

I
I

rtr

PERSON REPRESENTED (Show vour tull namc)

{L

& cltccl box -)

l-elony

Felr:',7 ( [-5ih0 1ci*;'ir:t O Misdcmcanor

r)'15,l!-ri
1\l1iein*Xiirv t5i*l tr;1'r3',
F",r..-1(1 r"5;11,1

F*<\rr.-rt:

{-Jiai':'li,6i0

Dofondmi-Adult

DOCKETNUMBERS

2tr

Dcfcndmt . Juvenilc

Msgis['ate

3D

Appellant

4El

Pmbation Violator

str

Puole Violator

ffi

Habcas Pothiohcr

---Court

7tr
8tr
etr

Dretrict Court

of APPcals

2255 Pciitioncr

Matdsl

Witsl63s

Ohcr (Spcci&)

Are you now emPloyed?

F No n

Yes

Am SelGEmPloYed

Name and address of emPloYer:

IF NO, give month and year of last employment

IF YES, how much do You

How much did You earn Per month? $

earn per month? $

I Yes E] No

If married is your SPouse emPloYed?

IF YES, how much does Your

OTHER
INCOME

IF YES, GIVE TF{E AMOLJNT

RECEIVED & TDENTIFY
THE SOURCES

accounts?
Have you any cash on hand or money in savings or checking

Yes

No IF YES,

slste total smount

furnishings and
or other valusble property (excluding ordinary household
Do you own any rcal estate, stocks, bonds, notes, automobiles,

clothing)?
PROP-

fl

Yes &tr

t'lo

IF YES, GIVE TFIE VALUE AND

DESCzuBE IT

ERTY

Dcpendcnts

SINGLE

]r'mnnreo

WIDOWED

sepARAteo on

OBLICATIONS&
DEBTS

List persons you actually support and your relationship to ftern

Tolsl
No. of

MARITAL STATUS

DEPENDENTS

DESCRIPTION

VALUE

DTVORCED

1
Monthly Paymt

APARTMENT

DEBTS &

OR HOME:

MONTHLY
BILLS
(LIST

AII

CREDMORS.

tl
$$

INCLUDIN6 BANKS,
LOAN COMP^NIES.
CHARC ACCOUNTS,
ETC )

Executed on (date)
I certifo under penalty ofperjury that the foregoing is true and correct.

SIGNATURE OF DEFENDANT
(OR PERSON REPRESENTID)

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';l

TJNITED STATES DISTRICT COURT

EASTERN DISTRICT OF MISSOURI
u

)
)

Plaintiff,

v.

Case No.

D>).c (\\os;f J*++,.g Clr.;:,i

Defendant,

ORIGINAL FILING FORM

BY THE FILING PARTY
THTS FORM MUST BE COMPLETED AND VERIFIED

WHEN INITTATING A NEW CASE.

COMPLAINT, wAS
THIS SAME CAUSE, oR A SUBSTANTIALLY EQUIVALENT
PREVIOUSLY FILED IN THIS COURT AS CASE NUMBER

AND ASSIGNED TO THE HONORABLE JUDGE

EQUIVALENT TO ANY
THIS CAUSE IS RELATED, BUT IS NOT SUBSTANTIALLY
AND

PRE,VIOUSLYFILEDCOMPLAINT'THERELATEDCASENUMBERIS

. THIS CASE MAY,

THAT CASE WAS ASSIGNED TO THE HONORABLE

THEREFORE, BE OPENED AS AN OzuGINAL PROCEEDING.

EQUIVALENT
NEITHER THIS SAME CAUSE, NOR A SUBSTANTIALLY

AND THEREFORE
CoMPLAINT, HAS BEEN PREVIoUSLY FILED IN THIS CoURT,

MAY BE OPENED AS AN ORIGINAL PROCEEDING.

is true and correct'

The undersigned affirms that the information provided above

nut",@

Signature of Filing

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