Instructions for this form: http://www.ca9.uscourts.gov/forms/form04instructions.pdf attach additional pages if necessaryFeedback or questions about this form? Email us at forms@ca9.uscourts.gov 1Rev. 12/01/2018 For both you and your spouse, estimate the average amount of money received from each of the followingsources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. Feedback or questions about this form? Email us at forms@ca9.uscourts.gov 2Rev. 12/01/2018 List your employment history for the past two years, most recent employer first.(Gross monthly pay is before taxes or other deductions.) List your spouse's employment history for the past two years, most recent employer first.(Gross monthly pay is before taxes or other deductions.) Feedback or questions about this form? Email us at forms@ca9.uscourts.gov 3Rev. 12/01/2018 How much cash do you and your spouse have?Below, state any money you or your spouse have in bank accounts or in any other financial institution. If you are a prisoner seeking to appeal a judgment in a civil action or proceeding, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account.List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinaryhousehold furnishing. Feedback or questions about this form? Email us at forms@ca9.uscourts.gov 4Rev. 12/01/2018 State every person, business, or organization owing you or your spouse money, and the amount owed. State the persons who rely on you or your spouse for support. If a dependent is a minor, list only the initialsand not the full name. Feedback or questions about this form? Email us at forms@ca9.uscourts.gov 5Rev. 12/01/2018 Estimate the average monthly expenses of you and your family. Show separately the amounts paid by yourspouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Feedback or questions about this form? Email us at forms@ca9.uscourts.gov 6Rev. 12/01/2018 Do you expect any major changes to your monthly income or expenses or in your assets or liabilities duringthe next 12 months? Have you spent227or will you be spending227any money for expenses or attorney fees in connection with thislawsuit? Provide any other information that will help explain why you cannot pay the docket fees for your appeal.State the city and state of your legal residence. Feedback or questions about this form? Email us at forms@ca9.uscourts.gov 7Rev. 12/01/2018