CONFIDENTIALIFP102 State ENG Rev 7/15www.mncourts.gov/formsPage 1 of 3State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: Plaintiff/Petitioner (first, middle, last)vs/and Defendant/Respondent (first, middle, last)Affidavit for Proceeding In Forma Pauperis (Minn. Stat 247563.01)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 pursing 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; I am receiving public assistance under some other means-tested programs. (Name the program)b. I have attached proof that I receive public assistance (such as MFIP card or canceled check from agency) or I will provide proof if requested. I receive Supplemental Security Income (SSI) as a resource for meeting my expenses.c. I am represented by attorney4. on behalf of a civil legal services program orvolunteer attorney program, based on indigency.5. . (Include yourself, your spouse, your minor children, and My family size is other dependents in your household. For my family size, I counted myself and (list all others): American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIALIFP102 State ENG Rev 7/15www.mncourts.gov/formsPage 2 of 3 Name Age: Relationship to you 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 ofmembers. I have attached proof of my family income or I will provide proof if requested.income is: My gross monthly income (before taxes and deductions) is7. My net (take home) monthly income is and the source of that Job/wages Unemployment Spousal Support Trust Income Social Security Other income is My spouse's gross monthly income (before taxes and deductions) is8.and the source of that OR, I do not know my spouse's income because:. I am not married.OR9.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 Income I receive 10.per month in child support (includes medical support and/orchild care support.child care support.per month in child support (includes medical support and/or I pay11.per month in court-ordered spousal support. I pay12.per month for I pay13. rent mortgage payment. My spouse's net (take home) monthly income is American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIALIFP102 State ENG Rev 7/15www.mncourts.gov/formsPage 3 of 3I own:14. Cash Checking, savings, and credit union acctsCars, 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)in debt, excluding car loans and real estate mortgage/loans. I am presently15.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 tohelp the Judge understand your situation):16. 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 County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com