CONFIDENTIALIFP114 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)Motion and Affidavit for Proceeding In Forma Pauperis in the Court of Appeals (Minn. Stat 247563.01 & Minn. R. App. P. 109)1. I believe that I have valid reasons for pursing this Court of Appeals action and I move for a court order granting me the following relief. waiving appellate court filing fees and cost bond payment for transcript preparation costs for the following hearing dates listed as follows Other (please specify): 2. I am a party in this action and in good faith I request an Order to proceed In Forma Pauperis. I have attached a copy of my statement of the case or petition being filed in the appellate court, showing the proposed issues on appeal.3. I am receiving public assistance under one or more of the following means-tested programs. SSI and/or MSA (Supplemental Security Income and Minnesota Supplemental Assistance) MFIP (Minnesota Family Investment Program); Food Stamps; General Assistance or Discretionary Work Program; MinnesotaCare, Medical Assistance, or General Assistance Medical Assistance; Energy Assistance; Other: (specify) Note: The court may ask you to provide proof of the type of public assistance you receive. 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 CONFIDENTIALIFP114 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.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 net (take home) monthly 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. American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIALIFP114 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