DISTRICT OF COLUMBIA COURT OF APPEALS __________________________, Appellant Appeal No. ______________ v. ___________________________, Appellee. MOTION FOR WAIVER OF PREPAYMENT OF COURT FEES AND COSTS (IN FORMA PAUPERIS) 1. I am not able to pay any of the court fees and costs I am able to pay only the following court fees and costs (specify): 2. My current street or mailing address is: 3. My occupation, employer, and employer's address are (specify): 4. My spouse's occupation, employer, and employer's address are (specify): American LegalNet, Inc. www.FormsWorkFlow.com 5. No, I am not receiving financial assistance. Yes, I am receiving financial assistance under one or more of the following programs: SSI (Social Security Supplemental Income) General Assistance for Children AFDC (Aide to Families with Dependent Children) Medical Assistance If you checked Yes on box 5, you must attach documents to verify receipt of the benefits; you may then skip item 6 and sign at the bottom of this form. 6. My income and available assets are not enough to pay for the common necessaries of life for me and the people in my family whom I support, and also to pay court fees and costs. [If you check this box, you must complete the attached Financial Statement, Form 7b.] Warning: You must immediately tell the court if you become able to pay court fees or costs during this action. I declare under penalty of perjury that the information on this form and all attachments is true and correct: Date: ___________________ _____________________________ (Type or print name) ____________________________ (Signature) CERTIFICATE OF SERVICE I hereby certify that I have hand-served or, mailed, postage prepaid, a copy of this motion to ___________________________________, this ____day of ______________, 20___. ______________________ Name American LegalNet, Inc. www.FormsWorkFlow.com