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Affidavit In Support Of Motion To Proceed On Appeal In Forma Pauperis Form. This is a Indiana form and can be use in General Appellate.
Tags: Affidavit In Support Of Motion To Proceed On Appeal In Forma Pauperis, Indiana Appellate, General
(SAMPLE AFFIDAVIT IN SUPPORT OF MOTION TO PROCEED ON APPEAL IN FORMA PAUPERIS) Form #App. R. 40-1 IN THE [INDICATE INDIANA COURT OF APPEALS OR GIVE NAME OF TRIAL COURT] NO. ____________________ ______________________________________________________________________________ ) Appeal from the _______ Court __________________________ ) [Insert name], Appellant, ) ) Trial Court Case No: vs. ) _____________________ ) ) The Honorable ________, Judge ) ) __________________________ ) [Insert name], Appellee. ) ______________________________________________________________________________ AFFIDAVIT IN SUPPORT OF MOTION TO PROCEED ON APPEAL IN FORMA PAUPERIS I, _____________, state, under penalties of perjury, that I am the [Appellant; Appellee] in the above-entitled case; that in support of my motion to proceed on appeal without being required to prepay fees, costs or give security therefor, I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am entitled to redress; and that the issues which I desire to present on appeal are the following: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ [INSERT ISSUES] I further 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. 1. Are you presently employed? c Yes cNo American LegalNet, Inc. www.USCourtForms.com a. b. 2. If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer. If the answer is no, state the date of your last employment and the amount of the salary and wages per month which you received. Have you received within the past twelve months any income from a business, profession or other form of self-employment, or in the form of rent payments, interest, dividends, retirement or disability payments, government benefits or other source? c Yes cNo a. 3. Do you own any cash or checking or savings account? c Yes cNo a. 4. If the answer is yes, state the total value of the items owned. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? a. 5. If the answer is yes, describe each source of income, and state the amount received from each during the past twelve months. If the answer is yes, describe the property and state its approximate value. List the persons who are dependent upon you for support and state your relationship to those persons. I understand that a false statement or answer to any questions in this affidavit will subject me to penalties for perjury. __________________________________________ Signature __________________________________________ Date 2 American LegalNet, Inc. www.USCourtForms.com