Motion for Permission to Appeal In Forma Pauperis and Affidavit United States Court of Appeals for the Eleventh Circuit Court of Appeals No. v. District Court No. Instructions: Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is 2230,224 223none,224 or 223not applicable (N/A),224 write in 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 case222s docket number, and the question number. 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. 247 1746; 18 U.S.C. 247 1621.) Date: Signed: 1. My issues on appeal are: Rev.: 6/18 American LegalNet, Inc. www.FormsWorkFlow.com 2 2. 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. Income Source Average monthly amount during the past 12 months Amount expected next month You Spouse You Spouse Employment $ $ $ $ Self-employment $ $ $ $ Income from real property (such as rental income) $ $ $ $ Interests 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: $ $ $ $ 3. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of Employment Gross Monthly Pay 4. List your spouse222s employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) 5. How much cash do you and your spouse have? $ American LegalNet, Inc. www.FormsWorkFlow.com 3 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. 6. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. Home (Value) Other Real Estate (Value) Motor Vehicle #1 (Value) Make & Year: Model: Registration #: Other Assets (Value) Other Assets (Value) Motor Vehicle #2 (Value) Make & Year Model: Registration #: 7. State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or your spouse money Amount owed to you Amount owed to your spouse American LegalNet, Inc. www.FormsWorkFlow.com 4 8. State the persons who rely on you or your spouse for support. Name [or, if under 18, initials only] Relationship Age 9. 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 For home-mortgage payment (include 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 $ $ Transportation (not including motor vehicle payments) $ $ Recreation, entertainment, newspapers, magazines, etc. $ $ Insurance (not deducted from wages or included in mortgage payments) $ $ Homeowner222s or renter222s $ $ 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: $ $ American LegalNet, Inc. www.FormsWorkFlow.com 5 Alimony, maintenance, and support paid to others $ $ Regular expenses for operation of business, profession, or farm (attach detailed statement) $ $ Other (specify): $ $ Total monthly expenses $ $ 10. 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. 11. Have you spent 226 or will you be spending 226 any money for expenses or attorney fees in connection with this lawsuit? Yes No If yes, how much: $ 12. Provide any other information that will help explain why you cannot pay the docket fees for your appeal. 13. State the city and state of your legal residence. Your daytime phone number: () Your age: Your years of schooling: American LegalNet, Inc. www.FormsWorkFlow.com