MotionandAffidavitforPermission to AppealInFormaPauperis
AppealNo.
v.DistrictCourtorAgencyNo.
AffidavitinSupportofMotion
Iswearoraffirmunderpenaltyofperjurythat,becauseof mypoverty,Icannotprepaythedocketfeesofmyappeal orpostabondforthem.IbelieveIamentitledtoredress. IswearoraffirmunderpenaltyofperjuryunderUnited Stateslawsthatmyanswersonthisformaretrueand correct. (28U.S.C.§1746;18U.S.C.§1621.)
Signed:
Instructions
Completeallquestionsinthisapplicationandthensignit.Do not leave any blanks: if the answer to a question is “0,” “none,” or “not applicable (N/A),” write in that response. If you needmorespacetoansweraquestionortoexplainyour answer, attach a separate sheet of paper identified with your name,yourcase’sdocketnumber,andthequestionnumber.
Date:
Myissuesonappealare:
1. Forbothyouandyourspouseestimatetheaverageamountof moneyreceivedfromeachof thefollowingsourcesduringthe past12 months.Adjustanyamountthatwasreceivedweekly,biweekly,quarterly,semiannually,or annuallytoshowthe monthly rate.Usegrossamounts,thatis,amountsbeforeanydeductionsfortaxesorotherwise.
IncomesourceAveragemonthlyamountduringAmountexpectednextmonth thepast12months
Employment / You$ / Spouse
$ / You
$ / Spouse
$
Self-employment / $ / $ / $ / $
Incomefromrealproperty
(suchasrentalincome) / $ / $ / $ / $
Interestanddividends / $ / $ / $ / $
Gifts / $ / $ / $ / $
Alimony / $ / $ / $ / $
Childsupport$$$$
Retirement(suchassocialsecurity,pensions,
annuities,insurance$$$$
Disability (suchassocialsecurity,
insurancepayments)$$$$Unemploymentpayments$ $ $ $
Public-assistance(suchas
welfare)$$$$
Other(specify):
$$$$
Totalmonthlyincome:$$$$
2. Listyouremploymenthistory,mostrecentemployerfirst.(Grossmonthlypayisbeforetaxesorotherdeductions.)
Employer
Address
Datesofemployment
Grossmonthlypay
3. Listyourspouse’semploymenthistory,mostrecentemployerfirst.(Grossmonthlypayisbeforetaxesorotherdeductions.)
Employer
Address
Datesofemployment
Grossmonthlypay
4. Howmuchcashdoyouandyourspousehave?$
Below,stateanymoneyyouoryourspousehaveinbankaccountsorinanyotherfinancialinstitution.
FinancialinstitutionTypeofaccountAmountyouhaveAmountyourspousehas
$$
$$
$$
Ifyouareaprisoner,youmustattachastatementcertifiedbytheappropriateinstitutionalofficershowingall receipts,expenditures,andbalancesduringthelastsixmonthsinyourinstitutionalaccounts. Ifyouhavemultiple accounts,perhapsbecauseyouhavebeeninmultipleinstitutions,attachonecertifiedstatementofeachaccount.
5. Listtheassets,andtheirvalues,whichyouownoryourspouseowns.Donotlistclothingandordinaryhouseholdfurnishings.
Home(Value)
Otherrealestate(Value)
Motorvehicle#1(Value)
Makeyear:
Model:
Registration#:
Motorvehicle#2(Value)
Makeyear:
Otherassets(Value)
Otherassets(Value)
Model:
Registration#:
6. Stateeveryperson,business,ororganizationowingyouoryourspousemoney,andtheamountowed.
Personowingyouoryourspouse money
AmountowedtoyouAmountowedtoyourspouse
7. Statethepersonswhorelyonyouoryourspouseforsupport.
NameRelationshipAge
8. Estimatetheaveragemonthlyexpensesofyouandyourfamily.Showseparatelytheamountspaidbyyourspouse. Adjustanypaymentsthataremadeweekly,biweekly,quarterly,semiannually,orannuallytoshowthe monthlyrate.
YouYourSpouse
Rentorhome-mortgagepayment(includelotrented
formobilehome)$$
Arereal-estatetaxesincluded? YesNo
Ispropertyinsuranceincluded?YesNo
Utilities(electricity,heatingfuel,water,sewer,and
telephone)$$
Homemaintenance(repairsandupkeep)$$
Food$$
Clothing$$
Laundryanddry-cleaning / $ / $Medicalanddentalexpenses / $ / $
Transportation(notincludingmotorvehiclepayments) / $ / $
Recreation,entertainment,newspapers,magazines,etc. / $ / $
Insurance(notdeductedfromwagesorincludedin
Mortgagepayments) / $ / $
Homeowner’sorrenter’s / $ / $
Life / $ / $
Health / $ / $
MotorVehicle / $ / $
Other: / $ / $
Taxes(notdeductedfromwagesorincludedin
Mortgagepayments)(specify): / $ / $
Installmentpayments
MotorVehicle / $ / $
Creditcard(name): / $ / $
DepartmentStore(name): / $ / $
Other: / $ / $
Alimony,maintenance,andsupportpaidtoothers / $ / $
Regularexpensesforoperationofbusiness,profession, orfarm(attachdetailedstatement) / $ / $
Other(specify): / $ / $
Totalmonthlyexpenses: / $ / $
9. Doyouexpectanymajorchangestoyourmonthlyincomeorexpensesorinyourassetsorliabilitiesduringthenext12 months?
YesNoIfyes,describeonanattachedsheet.
10. Haveyoupaid—orwillyoubepaying—anattorneyanymoneyforservicesinconnectionwiththiscase,includingthe completionofthisform? Yes No
Ifyes,howmuch?$
Ifyes,statetheattorney'sname,address,andtelephonenumber:
11. Haveyoupaid—orwillyoubepaying—anyoneotherthananattorney(suchasaparalegaloratypist)anymoneyfor servicesinconnectionwiththiscase,includingthecompletionofthisform?
YesNo
Ifyes,howmuch?$
Ifyes,statetheperson’sname,address,andtelephonenumber:
12. Provideanyotherinformationthatwillhelpexplainwhyyoucannotpaythedocketfeesforyourappeal.
13. Statetheaddressofyourlegalresidence.
Yourdaytimephonenumber:()
Yourage:
Youryearsofschooling:
ThefollowingCertificateofAuthorizedPrisonOfficialmustbecompletedandfiledwithaprisoner’sApplication toProceedwithoutPrepaymentofFeesandAffidavitforallincarceratedapplicants.See28U.S.C.§1915(a)(2) (a prisoner who applies to proceed without prepayment of feesmustprovide a certified copy of the trust fund accountstatement“obtainedfromtheappropriateofficialofeachprisonatwhichtheprisonerisorwasconfined”). The information provided below will be used by the Court in determining the proper initial partial filing fee as defined under 28 U.S.C. § 1915(b).
CERTIFICATE of AUTHORIZED PRISON OFFICIAL
I, , certify that the incarcerated applicant
(nameofapplicant) hasthesumof$onaccountto his/hercreditat(nameofinstitution) . I further certify that the Applicant named herein has the following securities to his/her credit:
.
Ifurthercertifythatinthe6-monthperiodimmediatelyprecedingthefilingofthecomplaint/petition/motionor noticeofappeal,theaveragemonthlydepositsto theapplicant’strustfundprisonaccountwas
$______, andtheaveragemonthlybalanceintheprisoner’saccountwas
$.
DATESIGNATURE OF AUTHORIZED OFFICIAL