IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLORADO Civil Action No. , Plaintiff(s)/Petitioner(s), v. , Defendant(s)/Respondents. MOTION AND AFFIDAVIT FOR LEAVE TO PROCEED ON APPEAL PURSUANT TO 28 U.S.C. § 1915 AND FED. R. APP. P. 24 I request leave to commence this appeal without prepayment of fees or security therefor pursuant to 28 U.S.C. § 1915 and Fed. R. App. P. 24. I also request that the United States pay for a transcript of the record of proceedings, if any, for inclusion in the record on appeal. In support of my requests, I submit the accompanying affidavit and declare that: (1) (2) I am unable to pay such fees or give security therefor. The issues I desire to raise on appeal are: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (3) (4) (5) I am entitled to redress. I take this appeal in good faith. The appeal is not frivolous and presents a substantial question. I swear that the responses which I have made to the questions and instructions below relating to my ability to pay the cost of prosecuting the appeal are true. MARITAL STATUS AND DEPENDENTS Rev. 1/12 American LegalNet, Inc. www.FormsWorkFlow.com Single ____ Married ____ Separated ____ Divorced ____ The following individuals are my dependents (Identify minor children by their initials only. Do not include their date of birth.): Name Age Relationship Name Age Relationship Name Age Relationship Name Age Relationship RESIDENCE Street Address: City: Zip Code: State: Telephone: EDUCATION What is the highest level of formal education you have received: __________________________ I can speak, read, write, and understand the English language: Yes _____ No _____ EMPLOYMENT If employed at present, complete the following: Name of employer: Address of employer: Telephone number of employer: How long have you been employed by present employer: Income: Monthly $ If self-employed, state your net income: Monthly $ What is the nature of your self-employment? If unemployed at present, complete the following: I have been unemployed since: Name of last employer: Address of last employer: Telephone number of last employer: Salary or hourly wage received from last employer: $ If spouse is employed, complete the following: Name of employer: How long has spouse been employed by present employer: Income: Monthly $ Weekly $ If receiving public assistance (e.g., welfare, unemployment benefits), complete the following: I have been receiving public assistance since: Monthly benefits: $ Weekly benefits: $ Weekly $ Weekly $ Rev. 1/12 2 American LegalNet, Inc. www.FormsWorkFlow.com REAL AND PERSONAL PROPERTY Real property: Do you own real property? Yes _____ No ______ If yes, describe: Address: Name(s) on title: Estimated value: $ Amount owed: $ Annual income from real property: $ Personal property: Automobile: Make: Name(s) on registration: Estimated value: $ Model: Amount owed: $ Year: Cash on hand: Total amount of cash in banks and savings and loan associations: $ Names and addresses of banks and associations: Other information pertinent to financial status: (Include stocks, bonds, savings bonds, interests in trusts either owned or jointly owned): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Payments for legal assistance: I have paid or will be paying an attorney, or someone other than an attorney (such as a paralegal or typist), money for services in connection with this case, including the No completion of this form. Yes If yes, how much? $ If yes, state the name, address, and telephone number of the attorney or person: FINANCIAL OBLIGATIONS: Rent on house or apartment: Mortgage on house: Gas bill: Electric bill: Telephone bill: Food: Clothing: Automobile loan: Automobile insurance: Other insurance: Payments to retail merchants: Rev. 1/12 MONTHLY PAYMENT: $ $ $ $ $ $ $ $ $ $ $ 3 American LegalNet, Inc. www.FormsWorkFlow.com Total owed: Payments on any other outstanding loans or debts: Total owed: Payments to doctors, hospitals, lawyers: Total owed: Maintenance under separation or dissolution agreement: Child support: Other Payments: Describe: Describe: Describe: Describe: Total monthly payments: $ $ $ $ $ $ $ $ $ Signature Name Street Address City Telephone Number Date: Signature of Affiant State Zip Code SUBSCRIBED AND SWORN TO BEFORE ME THIS ____ day of _____________________, 20____ Notary Public Address My commission expires:_________________________ Rev. 1/12 4 American LegalNet, Inc. www.FormsWorkFlow.com