__________________________________________ Full Name of Party Filing This Document __________________________________________ Mailing Address (Street or Post Office Box) __________________________________________ City, State and Zip Code __________________________________________ Telephone Number IN THE DISTRICT COURT OF THE ___________________ JUDICIAL DISTRICT OF THE STATE OF IDAHO, IN AND FOR THE COUNTY OF _____________________ Case No.: ___________________ _____________________________________, Plaintiff, MOTION AND AFFIDAVIT FOR PERMISSION TO PROCEED ON PARTIAL PAYMENT OF COURT FEES (PRISONER) vs. _____________________________________, Defendant. IMPORTANT NOTICE: Idaho Code § 31-3220A requires that you serve upon counsel for the county sheriff, the department of correction or the private correctional facility, whichever may apply, a copy of this motion and affidavit and any other documents filed in connection with this request. You must file proof of such service with the court when you file this document. STATE OF IDAHO ) ) ss. ) County of _ [ ] Plaintiff [ ] Defendant asks to start or defend this case on partial payment of court fees, and swears under oath . I 1. This is an action for (type of case) believe I’m entitled to get what I am asking for. MOTION AND AFFIDAVIT FOR PERMISSION TO PROCEED ON PARTIAL PAYMENT OF COURT FEES (PRISONER) PAGE 1 CAO 1-10C 2/25/2005 American LegalNet, Inc. www.USCourtForms.com 2. [ ] I have not previously brought this claim against the same party or a claim based on the same operative facts in any state or federal court. [ ] I have filed this claim against the same party or a claim based on the same operative facts in a state or federal court. 3. I am unable to pay all the court costs now. I have attached to this affidavit a current statement of my inmate account, certified by a custodian of inmate accounts, that reflects the activity of the account over my period of incarceration or for the last twelve (12) months, whichever is less. 4. I understand I will be required to pay an initial partial filing fee in the amount of 20% of the greater of: (a) the average monthly deposits to my inmate account or (b) the average monthly balance in my inmate account for the last six (6) months. I also understand that I must pay the remainder of the filing fee by making monthly payments of 20% of the preceding month’s income in my inmate account until the fee is paid in full. 5. I verify that the statements made in this affidavit are true. I understand that a false statement in this affidavit is perjury and I could be sent to prison for an additional fourteen (14) years. Do not leave any items blank. If any item does not apply, write “N/A”. Attach additional pages if more space is needed for any response. IDENTIFICATION AND RESIDENCE: Name: Other name(s) I have used: Address: How long at that address? Phone: Date and place of birth: DEPENDENTS: I am [ ] single [ ] married. If married, you must provide the following information: Name of spouse: MOTION AND AFFIDAVIT FOR PERMISSION TO PROCEED ON PARTIAL PAYMENT OF COURT FEES (PRISONER) PAGE 2 CAO 1-10C 2/25/2005 American LegalNet, Inc. www.USCourtForms.com My other dependents (including minor children) are: INCOME: Amount of my income: $ per [ ] week [ ] month Other than my inmate account I have outside money from: ________________________________________ My spouse’s income: $ ___________ per [ ] week [ ] month. ASSETS: List all real property (land and buildings) owned or being purchased by you. Your Address City State Legal Description Value Equity List all other property owned by you and state its value. Description (provide description for each item) Value Cash Notes and Receivables Vehicles: Bank/Credit Union/Savings/Checking Accounts Stocks/Bonds/Investments/Certificates of Deposit Trust Funds Retirement Accounts/IRAs/401(k)s Cash Value Insurance Motorcycles/Boats/RVs/Snowmobiles: Furniture/Appliances Jewelry/Antiques/Collectibles MOTION AND AFFIDAVIT FOR PERMISSION TO PROCEED ON PARTIAL PAYMENT OF COURT FEES (PRISONER) PAGE 3 CAO 1-10C 2/25/2005 American LegalNet, Inc. www.USCourtForms.com Description (provide description for each item) Value TVs/Stereos/Computers/Electronics Tools/Equipment Sporting Goods/Guns Horses/Livestock/Tack Other (describe) EXPENSES: List all of your monthly expenses. Expense Average Monthly Payment Rent/House Payment Vehicle Payment(s) Credit Cards: (list each account number) ____________________________________________________________________________ Loans: (name of lender and reason for loan) Electricity/Natural Gas Water/Sewer/Trash Phone Groceries Clothing Auto Fuel Auto Maintenance Cosmetics/Haircuts/Salons Entertainment/Books/Magazines Home Insurance MOTION AND AFFIDAVIT FOR PERMISSION TO PROCEED ON PARTIAL PAYMENT OF COURT FEES (PRISONER) PAGE 4 CAO 1-10C 2/25/2005 American LegalNet, Inc. www.USCourtForms.com Average Monthly Payment Expense Auto Insurance Life Insurance Medical Insurance Medical Expense Other ____________________________________________________________________________ ____________________________________________________________________________ MISCELLANEOUS: How much can you borrow? $ When did you file your last income tax return? From whom? _____ Amount of refund: $ PERSONAL REFERENCES: (These persons must be able to verify information provided) Name Address Phone Years Known ___________________________________ Signature ___________________________________ Typed or Printed Name SUBSCRIBED AND SWORN TO before me this ______ day of __________________, 20____. ___________________________________ Notary Public for Idaho Residing at My Commission expires MOTION AND AFFIDAVIT FOR PERMISSION TO PROCEED ON PARTIAL PAYMENT OF COURT FEES (PRISONER) PAGE 5 CAO 1-10C 2/25/2005 American LegalNet, Inc. www.USCourtForms.com