UNITED STATES COURT OF APPEALS FOR THE TENTH CIRCUIT Case No. __________________ Plaintiff/Petitioner - Appellant, v. Motion for Leave to Proceed on Appeal Without Prepayment of Costs or Fees Defendant/Respondent - Appellee. I, _________________________________________, the petitioner/appellant in the captioned case move this court for leave to proceed in forma pauperis. In support of this motion, I state that because of my poverty, I am unable to pay the costs of said proceedings or give security therefor, I submit the following financial declaration. American LegalNet, Inc. www.FormsWorkFlow.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-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 6/09 Page 2 American LegalNet, Inc. www.FormsWorkFlow.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. Amount expected next month You Spouse 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-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 6/09 Page 3 American LegalNet, Inc. www.FormsWorkFlow.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-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 6/09 Page 4 American LegalNet, Inc. www.FormsWorkFlow.com 6. State below the assets owned by you and your spouse. Do not list ordinary household furnishings and clothing. Home 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: $ _________ 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-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 6/09 Page 5 American LegalNet, Inc. www.FormsWorkFlow.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 $ ________ $ ________ Transportation (not including car payments) $ ________ $ ________ 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-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 6/09 Page 6 American LegalNet, Inc. www.FormsWorkFlow.com 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 A-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 6/09 Page 7 American LegalNet, Inc. www.FormsWorkFlow.com 10. Do you expect any major changes to your monthly income or expenses during the next four 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-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 6/09 Page 8 American LegalNet, Inc. www.FormsWorkFlow.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: A-14 Signature: Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 6/09 Page 9 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I hereby certify that on ____________________________ I sent a copy of [date] the foregoing Motion for Leave to Proceed on Appeal without Prepayment of Costs of Fees, to: _____________________________________, at ___________________________ ___________________________________________________________________ ______________________________________________, the last known address/email address, by _______________________. [state method of service] ____________ Date A-14 _____________________________ Signature Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 6/09 Page 10 American LegalNet, Inc. www.FormsWorkFlow.com