Affidavit to Accompany Motion for Leave to Appeal in Forma Pauperis District Court No.____________________ Appeal No. __________________________ v. Affidavit in Support of Motion I swear or affirm under penalty of perjury that, because of my poverty, I cannot prepay the docket fees of my appeal or post a bond for them. I believe I am entitled to redress. I swear or affirm under penalty of perjury under United States laws that my answers on this form are true and correct.(28 U.S.C. § 1746; 18 U.S.C. § 1621.) Signed: _______________________________ My issues on appeal are: Instructions Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is "0," "none," or "not applicable (N/A)," write in that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name, your case's docket number, and the question number. Date: ___________________________________ 1. For both you and your spouse estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. Income source Average monthly amount during Amount expected next month the past 12 months You $_________ $_________ $_________ Spouse $_________ $_________ $_________ You $_________ $_________ $_________ Spouse $_________ $_________ $_________ Employment Self-employment Income from real property (such as rental income) Interest and dividends $_________ $_________ $_________ $_________ American LegalNet, Inc. www.FormsWorkFlow.com Income source Average monthly amount during the past 12 months You $_________ $_________ $_________ Spouse $_________ $_________ $_________ $_________ Amount expected next month Gifts Alimony Child support You $_________ $_________ $_________ $_________ Spouse $_________ $_________ $_________ $_________ Retirement (such as social $_________ security, pensions, annuities, insurance Disability (such as social $_________ security, insurance payments) Unemployment payments Public-assistance (such as welfare) $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ Other (specify):___________ $_________ Total Monthly income: $_________ $_________ $_________ $_________ $_________ $_________ $_________ 2. List your employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions) Employer ___________________ ___________________ ___________________ Address ___________________ ___________________ ___________________ Dates of Employment ___________________ ___________________ ___________________ Gross monthly pay ___________________ ___________________ ___________________ 3. List your spouses's employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions) Employer ___________________ ___________________ ___________________ Address ___________________ ___________________ ___________________ Dates of Employment ___________________ ___________________ ___________________ Gross monthly pay ___________________ ___________________ ___________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com 4. How much cash do you and your spouse have? $_________________ Below, state any money you or your spouse have in bank accounts or in any other financial institution. Financial Institution ___________________ ___________________ ___________________ Type of Account ___________________ ___________________ ___________________ Amount you have $________ $________ $________ Amount your spouse has $________ $________ $________ If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account. 5. List the assets, and their values, which you or your spouse owns. Do not list clothing and ordinary household furnishings. Home (Value) Other real estate (Value) Motor Vehicle #1 (Value) ___________________________ ___________________________ ___________________________ Motor Vehicle #2 Model: __________________________ Make & year:________________ __________________________ Model:_____________________ __________________________ Registration#:________________ Other assets (Value) Other assets (Value) (Value) Make & year:________________ __________________________ ___________________________ __________________________ ___________________________ _________________________ ___________________________ _____________________ Registration#:_______________ 6. State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or your spouse money __________________________ __________________________ __________________________ Amount owed to you __________________________ __________________________ __________________________ Amount owed to your spouse __________________________ __________________________ __________________________ 7. State the persons who rely on you or your spouse for support. Name __________________________ __________________________ __________________________ Relationship __________________________ __________________________ __________________________ Age __________________________ __________________________ __________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com 8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. You $_________ Spouse $_________ Rent or home mortgage payment (include lot rented for mobile home) Are any real estate taxes included? 9 Yes 9 No Is property insurance included? 9 Yes 9 No Utilities (electricity, heating fuel, water, sewer, and Telephone) Home maintenance (repairs and upkeep) Food Clothing Laundry and dry-cleaning Medical and dental expenses Transportation (not including motor vehicle payments) Recreation, entertainment, newspapers, magazines, etc. Insurance (not deducted from wages or