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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.
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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
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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
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