CONFIDENTIALIFP201 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 2State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: Plaintiff/Petitioner (first, middle, last)vs. Defendant/Respondent (first, middle, last)Affidavit for Proceeding In Forma Pauperis (Inmate) (Minn. Stat 247247563.01, 563.02)1. I am a party in this action. I am not represented by counsel, I have been convicted of a felony and I am committed to the custody of the Commissioner of Corrections. I am either confined in a state correctional facility or I have been released from a state correctional facility under section Minn. Stat. 247247 244.065 or 244.07.2. I believe I have valid reasons for pursuing this action. In good faith, I request an order waiving court fees and costs. My pleadings (the Petition, Complaint, Answer, Appeal or other pleading) are attached. NOTE: If you are the person bringing the case, known as the plaintiff, the statute requires you provide the court with a copy of the Complaint before serving the complaint on the opposing party.3. The following information is required. You must complete each section.per month in child care support.g. I own the following property: a. I have the following dependents: b. My net (take home) monthly income is c. The source of my monthly income is d. If available to you, your spouse's net (take home) monthly income is e. I pay per month for rent/mortgage payment. f. I pay 5. Other personal property (jewelry, stocks, bonds, etc. - list separately)4. Real Estate (market value minus unpaid mortgage/loans) 3. Cars, other vehicles (list make, year and equity value (market value minus unpaid loans) for each 2. Checking, savings, and credit union accts 1. Cash a.b.b.a. American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIALIFP201 State ENG Rev 7/15www.mncourts.gov/formsPage 2 of 2in debt. h.I am presently b.a.i.I have the following monthly expenses: j.Other factors which support this are: (explain unusual medical expenses, emergenciesor other circumstances to help the judge understand your situation): 6. I have exhausted the inmate complaint procedure developed by the Commissioner ofCorrections before commencing this action against the Department of Corrections.7. My claim is not substantially similar to a previous claim brought against the same party,arising from the same facts, and which resulted in a adjudication on the merits.8. My full name is and I have been known by the following other names: 9. I have attached a copy of my most recent monthly statement showing the balance inmy inmate account. I authorize the Court to obtain at any time during the pendency ofthis action a current statement of the balance of my inmate account. NOTE: An inmatewho has funds in an inmate account may only proceed as a plaintiff in a civil action bypaying either the applicable court filing fee or 50% of the balance in the inmate account,whichever is less. If 50% of balance of the inmate account is used to commence the civilaction, the Commissioner of Corrections will continue to draw money out of the inmateaccount until the filing fee is paid in full.By signing this Affidavit, I am certifying that these statements are true under penalty of perjury. I understand that if I provide false information on the form it may lead to criminal charges. I understand that failure to execute the form or failure to provide information or requested records may result in denial of my motion to proceed In Forma Pauperis. I am authorizing that the facts contained in this Affidavit may be verified by any means required. Dated: Signature County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com