Form 4. Affidavit Accompanying Motion for Permission to Appeal In Forma Pauperis UNITED STATES DISTRICT COURT for the DISTRICT OF , Plaintiff(s) v. , Defendant(s) ) ) ) ) ) ) ) ) ) ) Case No. Affidavit in Support of Motion I swear or affirm under penalty of perjury that, because of my poverty, I cannot prepay the docket fees of my appeal or post a bond for them. I believe I am entitled to redress. I swear or affirm under penalty of perjury under United States laws that my answers on this form are true and correct. (28 U.S.C. � 1746; 18 U.S.C. � 1621.) Instructions Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is "0," "none," or "not applicable (N/A)," write that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name, your case's docket number, and the question number. Signed: _____________________________ Date: _____________________________ My issues on appeal are: 1. For both you and your spouse estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. Rev.: 12/13 Form 4 American LegalNet, Inc. www.FormsWorkFlow.com Income source Average monthly amount during the past 12 months You Spouse $ $ $ $ $ $ $ $ $ $ $ $ $ Amount expected next month You $ $ $ $ $ $ $ $ $ $ $ $ $ Spouse $ $ $ $ $ $ $ $ $ $ $ $ $ Employment Self-employment Income from real property (such as rental income) Interest and dividends Gifts Alimony Child support Retirement (such as social security, pensions, annuities, insurance) Disability (such as social security, insurance payments) Unemployment payments Public-assistance (such as welfare) Other (specify): Total monthly income: $ $ $ $ $ $ $ $ $ $ $ $ $ 2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Address Dates of employment Gross monthly pay $ $ $ Employer 3. List your spouse's employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Rev.: 12/13 Form 4 American LegalNet, Inc. www.FormsWorkFlow.com Employer Address Dates of employment Gross monthly pay $ $ $ 4. How much cash do you and your spouse have? $________ Below, state any money you or your spouse have in bank accounts or in any other financial institution. Financial Institution Type of Account Amount you have $ $ $ Amount your spouse has $ $ $ If you are a prisoner seeking to appeal a judgment in a civil action or proceeding, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account. 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. Other real estate (Value) $ Motor vehicle #1 (Value) $ Make and year: Model: Registration #: Home (Value) $ Motor vehicle #2 (Value) $ Make and year: Model: Other assets (Value) $ Other assets (Value) $ Rev.: 12/13 Form 4 American LegalNet, Inc. www.FormsWorkFlow.com Registration #: 6. State every person, business, or organization owing you or your spouse money, and the amount owed. Amount owed to you $ $ $ $ Amount owed to your spouse $ $ $ $ Person owing you or your spouse money 7. State the persons who rely on you or your spouse for support. Relationship Age Name [or, if under 18, initials only] 8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. You Your Spouse $ Rent or home-mortgage payment (including lot rented for mobile home) Are real estate taxes included? [ ] Yes [ ] No Is property insurance included? [ ] Yes [ ] No Utilities (electricity, heating fuel, water, sewer, and telephone) Home maintenance (repairs and upkeep) Food Clothing Laundry and dry-cleaning Medical and dental expenses $ $ $ $ $ $ $ $ $ $ $ $ $ Rev.: 12/13 Form 4 American LegalNet, Inc. www.FormsWorkFlow.com Transportation (not including motor vehicle payments) Recreation, entertainment, newspapers, magazines, etc. $ $ $ $ Insurance (not deducted from wages or included in mortgage payments) Homeowner's or renter's: Life: Health: Motor vehicle: Other: Taxes (not deducted from wages or included in mortgage payments) (specify): Installment payments Motor Vehicle: Credit card (name): Department store (name): Other: Alimony, maintenance, and support paid to others Regular expenses for operation of business, profession, or farm (attach detailed statement) Other (specify): Total monthly expenses: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? [ ] Yes [ ] No If yes, describe on an attached sheet. 10. Have you spent -- or will you be spending -- any money for expenses or attorney fees in connection with this lawsuit? [ ] Yes [ ] No If yes, how much? $ ____________ 11. Provide any other information that will help explain why you cannot pay the docket fees for your appeal. Rev.: 12/13 Form 4 American LegalNet, Inc. www.FormsWorkFlow.com 12. State the city and state of your legal residence. Your daytime phone number: (____) _______________ Your age: ________ Your years of schooling: ________ Last four digits of your social-security number: _______ (As amended Apr. 24, 1998, eff. Dec. 1, 1998; Apr. 28, 2010, eff. Dec. 1, 2010; Apr. 16, 2013, eff. Dec. 1, 2013.) Rev.: 12/13 Form 4 American LegalNet, Inc. www.FormsWorkFlow.com