Affidavit to Accompany Motion for Leave to Appeal in Forma Pauperis District Court No. Appeal No. v. 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.) Signed: My issues on appeal are: 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 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 case's docket number, and the question number. Date: 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. Income source Average monthly amount during the past 12 months You Employment Self-employment Income from real property (such as rental income) Interest and dividends Gifts Alimony Child support $ $ $ $ $ $ $ Spouse $ $ $ $ $ $ $ Amount expected next month You $ $ $ $ $ $ $ Spouse $ $ $ $ $ $ $ 1 American LegalNet, Inc. www.FormsWorkFlow.com 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, most recent employer first. (Gross monthly pay is before taxes or other deductions) Employer Address Dates of Employment Gross monthly pay 3. List your spouse's employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions) 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 2 American LegalNet, Inc. www.FormsWorkFlow.com If you are a prisoner, 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 or your spouse owns. Do not list clothing and ordinary household furnishings. Home (Value) Other real estate (Value) Motor Vehicle #1 Make & year: Model: Registration #: Other assets (Value) Motor Vehicle #2 Make & year: Model: Registration #: (Value) Other assets (Value) (Value) 6. 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 7. State the persons who rely on you or your spouse for support. Name Relationship Age 3 American LegalNet, Inc. www.FormsWorkFlow.com 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 Rent or home mortgage payment (include lot rented for mobile home) Are any 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) 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) $ Spouse $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 4 American LegalNet, Inc. www.FormsWorkFlow.com Other (specify): Total monthly expenses: $ $ $ $ 9. Do you expect any major changes to your monthly income or expenses in your assets or liabilities during the next 12 months? Yes No If yes, describe on attached sheet. 10. Have you paid -- or will you be 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, state the attorney's name, address and telephone number: 11. Have you paid -- or will you be paying -- anyone other than an attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion of this form? Yes No If yes, how much? $ If yes, state the person's name, address, and telephone number: 12. Provide any other information that will help explain why you cannot pay the docket fees for your appeal. 13. State the address of your legal residence. Your daytime phone number: Your age: Your years of schooling: 5 American LegalNet, Inc. www.FormsWorkFlow.com