251 Mo n t a n a S u p re m e C ou rt APP E AL W I T HOUT PAYING FI L ING F E E P AGE 1 OF 5 N a me Fo r m 5 ( a ) C i t y S t a t e Zip [e - mail address] [Designat i on of part y ] IN THE S UP R E M E C O U R T O F T H E ST A T E O F M O N T A NA N o . [to be as s igned by Cl er k of Supr e me Co u rt] , A pp e l l a n t , v. , A pp el l ee . M O T I O N T O P R O C EED ON A P P E A L W I T HO U T P AY I N G T HE F I LI N G F EE I m o ve th e Co u r t t o a l lo w t h is a pp e a l t o g o f o r w ar d w i t ho ut p a ying t h e filing f e e a nd su b m it t hi s A ffid a vi t in s u p po r t o f my m o t i o n: I, , a m t he [Name] [A p p e l la n t or A p p e l le e ] in t h e abo v e - e n t i t l e d m a t t e r . In supp o r t o f my a p pl i c at i o n t o p r o c ee d wi t ho ut p a ying t h e filing f e e , I s tat e th a t b ec a u se o f my f in a nc i a l c o ndi t i o n, I a m un a b l e t o p a y t h e f il ing f ee . I b el i e ve t h e D is tr i ct Co u r t m a de m is ta k e s a nd t h a t t h is Co u rt American LegalNet, Inc. www.FormsWorkFlow.com 251 Mo n t a n a S u p re m e C ou rt APP E AL W I T HOUT PAYING FI L ING F E E P AGE 2 OF 5 wi l l d e cide t he se issu e s in m y f a v o r o n a pp e a l : [Li s t the mi s takes yo u b e li eve t h e D i str i ct Court ma d e.] 1. 2. 3 . I sw e a r m y a nsw e r s t o t h e f o l l o wing q ue s t i o ns ar e tr u e: 1. D o yo u h a ve a j o b? Y e s No If y o u d o , s tat e t h e a m o unt o f yo ur l a st p a y c he ck, a nd g ive t h e na me a nd a dd r e ss o f y o ur em p lo y e r : If yo u do n o t h a ve a j o b , whe n did y o u l a st wo r k, a nd ho w mu c h did y o u m a ke t h e l a st m o n t h yo u w or k e d? 2. D id a n yo ne g ive y o u m o n e y f o r w o r k y o u h a ve d o n e , f o r s a le o f ar t o r c ra f t s yo u h a ve m a d e , da y l ab o r , o r a ny o t h e r s o u r ce du r ing t h e p a st yea r ? Y e s No If yo u a nsw e r e d y e p l e a se d e sc r i b e t h e s o u r ce o f t h e i nc o me or a ssis t a nce a nd t h e a m o unt o f inc o me p e r m o n th. American LegalNet, Inc. www.FormsWorkFlow.com 251 Mo n t a n a S u p re m e C ou rt APP E AL W I T HOUT PAYING FI L ING F E E P AGE 3 OF 5 3 . H a s a n y o ne g iv e n yo u a loa n o r o t he r m o n e y a s t e mp o r ar y a ssis t a nc e? Y e s No If yo u a nsw e r e d y e p le as e g ive t h e a m o unt a nd w he n t h e m o n e y is t o be r e p a id: 4. Ar e yo u re c e iving a ny c he cks, m o n e y o r b e n e fi t s f r o m a ny o f t h e f ol l o w i ng s o u r c e s? S o ci a l S e cu r i t y D is a b il i t y Insu ra nce ( S S D I) S o ci a l S e cu r i t y Inc o me ( SSI) T e mp ora r y A ssi s t a nce f o r N ee dy F a m ili e s ( TA N F ) W o r k e r s Co mp e ns at i o n b e n e fi t s Ot he r di s a b ili t y b e n e fi t s Pu b lic a s sis ta nce o f a ny t ype Give t h e s o u r c e s a n d a m o u nt s o f t h e be n e fi t s o r a ssis t a nc e : 5. D o yo u h a ve a ny che cking o r s a vin g s a cc o un t s? Y e s No If y o ur a n sw e r w a s ye s, s tat e t h e p r e s e nt b a l a n c e in e a ch a cc o un t : 6. D o y o u o wn a ny v eh icl e s, l a nd, b ui l din g s, s t o cks, b o nds, n ot e s, o r o t h e r v a lu a b l e p r o p er t y ( do n o t i n c l ude o r din ar y h o me fu r ni s h in g s a nd c lo t h in g) ? Y e s No If y o u s a i d, y e d e sc r i b e e a ch i t e m a nd g ive i t s a p p r o xim a t e v al u e : American LegalNet, Inc. www.FormsWorkFlow.com 251 Mo n t a n a S u p re m e C ou rt APP E AL W I T HOUT PAYING FI L ING F E E P AGE 4 OF 5 7. A r e yo u m a r r i ed ? Y e s No N a me o f sp o us e : 8. Doe s y o u r sp o use h a ve a j o b o r h a ve a ny r e s o u r c e s t o a ssist y o u b y p a ying t he fi l ing f ee ? 9. D o yo u h a ve a n o b li g at i o n t o supp or t a n yo ne e ls e? Y e s No I f yo u s a id, y e s , g ive e a ch p e r s o n a m e , ho w y o u ar e r el at e d , a nd h o w much yo u p a y t o w a r d e a ch pe r s o supp o r t p e r m o n t h: ST A T E O F M O N T A NA ) : ss. Co un t y o f ) I sw e a r t h a t e v e r y t h ing s t a t e d in t h is mo t i o n a nd a ffi d a vit is t r ue a n d c o rr e ct t o t h e b e s t o f my kn o wl e d ge. D A TED th is d a y o f , 20 . [ Se a l] [Signatur e ] [Signature of N o tary Public] American LegalNet, Inc. www.FormsWorkFlow.com 251 Mo n t a n a S u p re m e C ou rt APP E AL W I T HOUT PAYING FI L ING F E E P AGE 5 OF 5 [Typed or printed n a me] [Title] [Resi d ing at] My comm i ssion expi r es : . American LegalNet, Inc. www.FormsWorkFlow.com