UNITED STATES COURT OF APPEALS FOR THE TENTH CIRCUIT Plaintiff/Petitioner - Appellant, Case No. __________________ v. Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed Without Prepayment of Costs or Fees Defendant/Respondent - Appellee. NOTICE AND INSTRUCTIONS If you proceed on appeal pro se, the court will accept a properly completed Form A-12 in lieu of a formal brief. This form is intended to guide you in presenting your appellate issues and arguments to the court. If you need more space, additional pages may be attached. A short statement of each issue presented for review should precede your argument. Citations to legal authority may also be included. This brief should fully set forth all of the arguments that you wish the court to consider in connection with this case. New issues raised for the first time on appeal generally will not be considered. An appeal is not a retrial but rather a review of the proceedings in the district court. A copy of the completed form must be served on all opposing counsel and on all unrepresented parties and a proper certificate of service furnished to this court. A form certificate is attached. American LegalNet, Inc. www.USCourtForms.com APPELLANT/PETITIONER’S OPENING BRIEF 1. Statement of the Case. (This should be a brief summary of the proceedings in the district court.) 2. Statement of Facts Relevant to the Issues Presented for Review. A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 2 American LegalNet, Inc. www.USCourtForms.com 3. Statement of Issues. a. First Issue: Argument and Authorities: b. Second Issue: Argument and Authorities: A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 3 American LegalNet, Inc. www.USCourtForms.com 4. Do you think the district court applied the wrong law? If so, what law do you want applied? 5. Did the district court incorrectly decide the facts? If so, what facts? 6. Did the district court fail to consider important grounds for relief? If so, what grounds? 7. Do you feel that there are any other reasons why the district court’s judgment was wrong? If so, what? 8. What action do you want this court to take in your case? 9. Do you think the court should hear oral argument in this case? If so, why? _________________________ Date ___________________________________ Signature A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 4 American LegalNet, Inc. www.USCourtForms.com FINANCIAL DECLARATION Affidavit to Accompany Motion for Permission to Appeal in Forma Pauperis I swear or affirm under penalty of perjury that because of my poverty I am unable to pay the docket fees of my appeal or to post a bond for them. I believe I am entitled to a different result than that reached in the district court. I further swear or affirm under penalty of perjury that the responses which I have made to the questions and instructions below relating to my ability to pay the fees for my appeal are true. Instructions. Please complete all questions in this application and then sign it on the last page. If the answer to any question is "0" or "none," or the question is "not applicable", so indicate by writing "0", "none", or "not applicable (N/A)". If additional space is needed to answer any question or to explain your answer to any question, please use and attach a separate sheet of paper identified with your name, the docket number of your case and the number of the question. My issues on appeal are: 1. Are you or your spouse currently employed? Yes _____ No _____ 2. If you or your spouse are currently employed, state the name and address of your employer, the length of your employment with that employer, and your monthly gross pay. Gross pay is pay before any taxes or other deductions are taken. If you have more than one employer, please provide the information requested below about the other employer(s) on a separate sheet of paper and attach it to this application. A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 5 American LegalNet, Inc. www.USCourtForms.com Yourself: Your Spouse: Name and Address of Employer Name and Address of Employer _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Length of Employment _____ ______ Years Months Length of Employment _____ ______ Years Months Monthly Gross Pay $____________ Monthly Gross Pay $____________ 3. If you are currently unemployed, state the date of your last employment and your monthly gross pay during your last month of employment. Gross pay is pay before any taxes or other deductions are taken. Date of last employment (Month/Year) for yourself _______________; spouse _____________ Monthly gross pay during last month of employment $____________ 4. State whether you or your spouse have received money from any of the following sources during the past twelve months, and, if so, the average monthly amount from that source. Adjust any money that was received weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. Did you receive money from any of the following sources during the past 12 months? Average monthly amount during past 12 months for you and your spouse if applicable. You Spouse Amount expected next month You Spouse Self-employment Y/N ___ $ _______ $ _______ $ _______ $ _______ Income from real property (such as rental income) Y/N ___ $ _______ $ _______ $ _______ $ _______ Interest and dividends Y/N ___ $ _______ $ _______ $ _______ $ _______ Gifts Y/N ___ $ _______ $ _______ $ _______ $ _______ Alimony Y/N ___ $ _______ $ _______ $ _______ $ _______ Y/N ___ $ _______ $ _______ $ _______ $ _______ Child Support A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 6 American LegalNet, Inc. www.USCourtForms.com Retirement income from sources such as social security, private pensions, annuities, or insurance policies Y/N ___ $ _______ $ _______ $ _______ $ _______ Disability payments such as social security, other state or federal government, or insurance payments Y/N ___ $ _______ $ _______ $ _______ $ _______ Unemployment payments Y/N ___ $ _______ $ _______ $ _______ $ _______ Public assistance payments such as welfare payments Y/N ___ $ _______ $ _______ $ _______ $ _______ Other sources of money (specify: ____________________) Y/N ___ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ TOTAL 5. State the amount of cash you and your spouse have: $ ___________ State below any money you or your spouse have in savings, checking, or other accounts in a bank or other financial institution. Bank or Other Financial Institution: Type of Account such as savings, checking, or CD: Amount you have: Amount your spouse has: __________________________________ ________________ $ _________ $ _________ __________________________________ ________________ $ _________ $ _________ __________________________________ ________________ $ _________ $ _________ A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 7 American LegalNet, Inc. www.USCourtForms.com 6. State below the assets owned by you and your spouse. Do not list ordinary household furnishings and clothing. Address: Value: $ _________ _________________________________ Amount owed on mortgages and _________________________________ liens: $ _________ Other real Address: Value: $ _________ estate _________________________________ Amount owed on mortgages and _________________________________ liens: $ _________ Model/Year: Value: $ _________ ________________________ Amount owed: $ _________ Model/Year: Value: $ _________ ________________________ Amount owed: $ _________ Description: ______________________ Value: $ ________ _________________________________ Amount owed: $ _________ Home Motor vehicle Motor vehicle Other 7. State below any person, business, organization, or governmental unit that owes you or your spouse money and the amount that is owed. Name of Person, Business, or Organization Amount Owed Amount Owed that Owes You or Your Spouse Money You: Your Spouse: __________________________________ $ _________ $ _________ __________________________________ $ _________ $ _________ A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 8 American LegalNet, Inc. www.USCourtForms.com 8. State the individuals who rely on you and your spouse for support. Indicate their relationship to you, their age, and whether they live with you. Name Relationship Age Does this person live with you? ___________________ ________________ _________ Yes _____ No _____ ___________________ ________________ _________ Yes _____ No _____ ___________________ ________________ _________ Yes _____ No _____ ___________________ ________________ _________ Yes _____ No _____ 9. Complete this question by estimating the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. You Spouse $ ________ $ ________ Utilities: Electricity and heating fuel $ ________ $ ________ Water and sewer $ ________ $ ________ Telephone $ ________ $ ________ $ ________ $ ________ Home maintenance (Repairs and upkeep) $ ________ $ ________ Food $ ________ $ ________ Clothing $ ________ $ ________ Laundry and dry cleaning $ ________ $ ________ Medical and dental expenses $ ________ $ ________ Rent or home mortgage payment (include lot rented for mobile home) Are real estate taxes included? Yes ____ No ____ Is property insurance included? Yes ____ No ____ Other ___________________ A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 9 American LegalNet, Inc. www.USCourtForms.com Transportation (not including car payments) $ ________ $ ________ Recreation, clubs and entertainment, newspapers, magazines, etc. $ ________ $ ________ Charitable contributions $ ________ $ ________ Homeowner's or renter's $ ________ $ ________ Life $ ________ $ ________ Health $ ________ $ ________ Auto $ ________ $ ________ Other ___________________ $ ________ $ ________ Insurance (not deducted from wages or included in home mortgage payments) Taxes (not deducted from wages or included in home mortgage payments) (specify) __________________________________ $ ________ Installment payments Auto: $ ________ $ ________ Credit Card: (name) ____________________ $ ________ $ ________ Department Store: (name) ________________________ $ ________ $ ________ Other ___________________ $ ________ $ ________ Other ___________________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ (attach detailed statement) $ ________ $ ________ Other ___________________ $ ________ $ ________ $ ________ $ ________ Alimony, maintenance, and support paid to others Payments for support of additional dependents not living at your home Regular expenses from operation of business, profession, or farm TOTAL MONTHLY EXPENSES 10. Do you expect any major changes to your monthly income or expenses during the next four A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 10 American LegalNet, Inc. www.USCourtForms.com months? Yes _____ No _____ If yes, describe. 11. Have you paid an attorney any money for services in connection with this case, including the completion of this form? Yes _____ No _____ If yes, how much? $ _________ If yes, provide the name, address, and telephone number of the attorney: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Have you promised to pay or do you anticipate paying an attorney any money for services in connection with this case, including the completion of this form? Yes _____ No _____ If yes, how much? $ _________ If yes, provide the name, address, and telephone number of the attorney: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 12. Have you paid anyone other than an attorney (such as a paralegal, typing service, or another person) any money for services in connection with this case, including the completion of this form? Yes _____ No _____ If yes, how much? $ _________ If yes, provide the name, address, and telephone number of the person or service: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 11 American LegalNet, Inc. www.USCourtForms.com 13. Have you promised to pay or do you anticipate paying anyone other than an attorney (such as a paralegal, typing service, or another person) any money for services in connection with this case, including the completion of this form? Yes _____ No _____ If yes, how much? $ __________ If yes, provide the name, address, and telephone number of the person or service: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 14. How much can you pay each month toward the docket fee for your appeal. $ ______________ 15. Please provide any other information that helps to explain why you are unable to pay the docket fees for your appeal. 16. State the address of your legal residence: ___________________________________________________ ___________________________________________________ ___________________________________________________ Your daytime phone number: (______)___________________ Your age: __________________ Years of schooling: _____________________ Your social security number: ____________________ I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA THAT THE FOREGOING IS TRUE AND CORRECT. 28 U.S.C. § 1746, 18 U.S.C. § 1621. Date: Signature: A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 12 American LegalNet, Inc. www.USCourtForms.com CERTIFICATE OF SERVICE I hereby certify that on ____________________________ I sent a copy [date] of the foregoing Appellant’s Brief and Motion for Leave to Proceed on Appeal without Prepayment of Costs of Fees, to: _____________________________________, at ___________________________ ___________________________________________________________________ ______________________________________________, the last known address, by way of United States mail or courier. _____________________________________ _____________________________ Date Signature A-10 Appellant/Petitioner’s Opening Brief and Motion for Leave to Proceed In Forma Pauperis (NON-PLRA) 1/99 Page 13 American LegalNet, Inc. www.USCourtForms.com