Affidavit For Proceeding In Forma Pauperis
Affidavit For Proceeding In Forma Pauperis Form. This is a Minnesota form and can be use in District Court Statewide.
Tags: Affidavit For Proceeding In Forma Pauperis, IFP-102, Minnesota Statewide, District Court
CONFIDENTIAL State of Minnesota District Court County Judicial District: Court File Number: Case Type: Affidavit for Proceeding In Forma Pauperis Plaintiff/Petitioner vs / and (Minn. Stat. § 563.01) Defendant/Respondent STATE OF MINNESOTA ) ) SS ) COUNTY OF 1. I am a party in this action. I am a natural person (not a corporation, partnership or other entity). In good faith, I request a court order waiving court fees and costs. I cannot support my family and myself and also pay or give security for costs. 2. I believe that I have valid reasons for pursuing this action. My pleadings (the Petition, Complaint, Answer, Appeal or other pleading) are attached. 3. a. I am receiving public assistance under one or more of the following means-tested programs: MSA (Minnesota Supplemental Assistance Programs); MFIP (Minnesota Family Investment Program); Food Stamps; General Assistance or Discretionary Work Program; MinnesotaCare, Medical Assistance, or General Assistance Medical Assistance; Energy Assistance; b. I am receiving public assistance under some other means-tested program: (Name the program) I have attached proof that I receive public assistance (such as MFIP card or cancelled check from agency) or I will provide proof if requested. c. I receive Supplemental Security Income (SSI) as a resource for meeting my expenses. 4. I am represented by attorney on behalf of a civil legal services program or volunteer attorney program, based on indigency. 5. My family size is ___________. (Include yourself, your spouse, your minor children, and other dependents in your household.) For my family size, I counted myself and (list all others): Name IFP102 State Age ENG Rev 07/15 Relationship to you www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 CONFIDENTIAL 6. My gross annual family income (before taxes and deductions) is $ which is less than 125% of the Federal Poverty Line for my family size of _________ members. I have attached proof of my family income or I will provide proof if requested. 7. My gross monthly income before taxes and deductions is $ . My net (take home) monthly income is $ , and the source of that income is: Job / wages Unemployment Spousal Support Trust Income Social Security Other: _______________________________________________________________ 8. My spouse’s gross monthly income before taxes and deductions is $ My spouse’s net (take home) monthly income is $ , and the source of that income is ; OR, I do not know my spouse’s income because: OR I am not married. 9. All other family members and dependents living with me have net monthly income as follows: Name of person Age Net (take home) monthly income Source of that Income 10. I receive $ and/or child care support. 11. I pay $_____________ per month in court-ordered child support (includes medical support and/or child care support). 12. I pay $ 13. I pay $_____________ per month for rent mortgage payment. 14. I own: Cash $ Checking, savings and credit union accts $ Cars, other vehicles (list make, year and equity value [market value minus unpaid loans]) _________________________________ $ _________________________________ $ Real Estate (market value minus unpaid mortgage/loans) Homestead: $ Other Real Estate: $ Other personal property (jewelry, stocks, bonds, etc. - list separately) _________________________________ $ _________________________________ $ 15. I am presently $____________ in debt, excluding car loans and real estate mortgage/loans. IFP102 State per month in child support (includes medical support per month in court-ordered spousal support. ENG Rev 07/15 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 CONFIDENTIAL 16. Other factors which support your request are (explain unusual medical expenses, emergencies, reasons that the family money is not available to you, or other circumstances to help the Judge understand your situation): By signing this Affidavit, I am certifying that these statements are true under penalty of perjury. I understand that if I provide false information on the form it may lead to criminal charges. I understand that failure to execute the form or failure to provide information or requested records may result in denial of my motion to proceed In Forma Pauperis. I am authorizing that the facts contained in this Affidavit may be verified by any means required. Dated: Signature Name: Address: City/State/Zip: Telephone: ( ) E-mail address: ____________________________ IFP102 State ENG Rev 07/15 www.mncourts.gov/forms American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3