Petition and Affidavit for Proceeding In Forma Pauperis
Petition and Affidavit for Proceeding In Forma Pauperis Form. This is a Minnesota form and can be use in District Court Statewide.
Tags: Petition and Affidavit for Proceeding In Forma Pauperis, IFP-401, Minnesota Statewide, District Court
CONFIDENTIAL State of Minnesota District Court County Judicial District: Court File Number: Case Type: In Re: □ Guardianship □ Conservatorship Petition and Affidavit for Proceeding In Forma Pauperis and (Minn. Stat. § 563.01; § 524.5-502) □ Respondent □ Ward □ Protected Person State of Minnesota ) ) SS ) County of TO THE HONORABLE JUDGE OF THE ABOVE-NAMED COURT: 1. Under the authority of Minn. Stat. § 563.01, and upon the Affidavit of the Petitioner filed with the court, the undersigned moves the court for an Order granting the following relief: a. Permitting the Petitioner to proceed In Forma Pauperis without prepayment of filing fee, and certified copy and photocopy fees. b. Directing the District Court Administrator to perform the duties of the office without requiring the Petitioner to pay a filing fee, certified copy and photocopy fees. Directing the county of financial responsibility to pay reasonable attorney’s fees c. for the attorney appointed to represent the proposed ward/protected person. d. 2. Granting such other further relief as may be proper. I have filed the petition to appoint a guardian and/or conservator for the above referenced Respondent. IFP401 State ENG Rev 2/16 www.mncourts.gov/forms Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL Accompanying this Affidavit or already on file herein is the Petition for Appointment of 3. Guardian and/or Conservator. Said Petition sets forth the Respondent’s address, and other information, to the best of my knowledge. 4. a. The Respondent is receiving public assistance under one or more of the following means-tested programs: MSA (Minnesota Supplemental Assistance Programs) MFIP (Minnesota Family Investment Program) Food Stamps General Assistance or Discretionary Work Program MinnesotaCare, Medical Assistance, or General Assistance Medical Assistance Energy Assistance b. The Respondent is receiving public assistance under some other means-tested program: (Name the program) I have attached proof that Respondent receives public assistance (such as MFIP card or cancelled check from agency) or I will provide proof if requested. c. The Respondent receives Supplemental Security Income (SSI) as a resource for meeting expenses. 5. Respondent is represented by attorney on behalf of a civil legal services program or volunteer attorney program, based on indigency. Respondent’s family size is ___________. (Include Respondent, Respondent’s spouse, minor children, and other dependents in Respondent’s household, if any.) For family size, count Respondent and (list all others): Name Age Relationship to you 6. IFP401 State ENG Rev 2/16 www.mncourts.gov/forms Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL 7. Respondent’s gross annual family income (before taxes and deductions) is $ which is less than 125% of the Federal Poverty Line for a family size of members. I have attached proof of Respondent’s family income or I will provide proof if requested. 8. Respondent’s gross monthly income before taxes and deductions is $ Respondent’s net (take home) monthly income is $ , and the source of that income is: Job / wages Unemployment Spousal Support Trust Income Social Security Other: 9. Respondent’s spouse’s gross monthly income before taxes and deductions is Respondent’s spouse’s net (take home) monthly income is $ the source of that income is , and ; OR, I do not know Respondent’s spouse’s income because: OR Respondent is not married. 10. All other family members and dependents living with Respondent have net monthly income as follows: Name of person Age Net (take home) monthly income Source of that Income 11. Respondent receives $ per month in child support (includes medical support and/or child care support. 12. Respondent pays $_____________ per month in court-ordered child support (includes medical support and/or child care support). 13. Respondent pays $ per month in court-ordered spousal support. 14. Respondent pays $_____________ per month for rent mortgage payment. 15. The probable value and general character of the assets of the Respondent are Cash $ Checking, savings and credit union accts $ Cars, other vehicles (list make, year and equity value (market value minus unpaid loans)) _________________________________ _________________________________ IFP401 State $ $ ENG Rev 2/16 www.mncourts.gov/forms Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL Real Estate (market value minus unpaid mortgage/loans) Homestead: $ Other Real Estate: $ Other personal property (jewelry, stocks, bonds, etc. - list separately) _________________________________ _________________________________ 16. $ $ Respondent is presently $____________ in debt, excluding car loans and real estate mortgage/loans. 17. Other factors which support this request are: (explain unusual medical expenses, emergencies, reasons that the family money is not available to Respondent, or other circumstances to help the Judge understand Respondent’s situation): 18. I believe that I have good grounds for the relief applied for in this petition for guardianship and/or conservatorship. However, I have been unable to proceed in this matter because the Respondent does not have funds to pay the filing fee, service of process, attorney’s fees for the attorney appointed to represent the proposed Respondent, and other court-related costs. 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 Name: Address: City/State/Zip: Telephone: ( ) E-mail address: IFP401 State ENG Rev 2/16 www.mncourts.gov/forms Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com