Telephone FPD Apptd CJA Pro Per UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA UNITED STATES OF AMERICA, PLAINTIFF, CASE NUMBER: CASE NUMBER: Case Number Under Which Sentence was Imposed MOTION AND AFFIDAVIT FOR LEAVE TO APPEAL IN FORMA PAUPERIS: 28 U.S.C. 753(f) 28 U.S.C. 1915 FROM JUDGMENT RENDERED BY A MAGISTRATE JUDGE IN A CRIMINAL CASE / CVB CASE v. DEFENDANT/ VIOLATOR. The undersigned , a party in this action, moves the Court under 28 USC § 1915 for authorization to prosecute an appeal without prepayment of fees and costs or security therefor, and for the preparation of a transcript at government expense. 1. I believe I am entitled to appeal the judgment, and the issues which I desire to present on my proposed appeal are the following: a. b. c. 2. I am unable to pay the costs of the proposed appeal proceeding or to give security therefor. I swear that the following responses are true. a. Are you presently employed? Yes No. If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer: b. Have you received, within the past twelve months, any income from a business, profession or other form of selfemployment, or in the form of rent payments, interest, dividends, or other source? Yes No. If the answer is yes, describe each source of income and state the amount received from each during the past twelve months. M-23 (12/11) MOTION AND AFFIDAVIT FOR LEAVE TO APPEAL IN FORMA PAUPERIS: 28 U.S.C. 753(f), 28 U.S.C. 1915 FROM JUDGMENT Page 1 of 2 RENDERED BY A MAGISTRATE JUDGE IN A CRIMINAL CASE: CVB/CITATION NUMBER. American LegalNet, Inc. www.FormsWorkFlow.com c. Are you presently employed in prison? Yes No. If yes, state the number of hours you work per week and the hourly rate of pay. d. Do you have money in a checking or savings account? Yes No. If the answer is yes, state the amount of money in each account separately as of six (6) months prior to the date of this affidavit: e. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes No. f. In what year did you last file an income tax return? g. Approximately how much income did your last tax return reflect? h. Are there persons who are dependent upon you for support? If the answer is yes, state your relationship to those persons: Yes No. i. State monthly expenses, itemizing the major items: Signature of Party I declare under penalty of perjury that the foregoing is true and correct. Date Signature of Attorney (Disregard if filed in propria persona) M-23 (12/11) MOTION AND AFFIDAVIT FOR LEAVE TO APPEAL IN FORMA PAUPERIS: 28 U.S.C. 753(f), 28 U.S.C. 1915 FROM JUDGMENT Page 2 of 2 RENDERED BY A MAGISTRATE JUDGE IN A CRIMINAL CASE: CVB/CITATION NUMBER. American LegalNet, Inc. www.FormsWorkFlow.com