Form 4. Affidavit Accompanying Motion for Permission to Appeal In Forma Pauperis United States District Court for the _____________ District of ________ A.B., Plaintiff, Docket No.: __________ v. C.D., Defendant. Affidavit in Support of Motion I swear or affirm under penalty of perjury that, because of my poverty, I cannot repay 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 "O," "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 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 last twelve (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. American LegalNet, Inc. www.USCourtForms.com Income Source Average Monthly Amount During the Past Twelve (12) Months YOU Amount Expected Next Month YOU $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ __ ____ Employment Self-employment Income from real property (such as rental income) Interest and dividends Gifts Alimony Child support Retirement (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 $ _________ $ _________ $ _________ ____________________________ ____________________________ ____________________________ American LegalNet, Inc. www.USCourtForms.com 4. How much cash do you or your spouse have? $___________. Type of Account _________________ _________________ _________________ Amount You Have $ __________ $ __________ $ __________ Amount Your Spouse Has $__________ $ _________ $ _________ Financial Institution ____________________________ ____________________________ ____________________________ 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 own or your spouse owns. Do not list clothing and ordinary household furnishings. Home (value) ___________________ ____________________ Other Real Estate _________________ _________________ Motor Vehicle #1 (value) Make & Year: _________________ Registration: _________________ Motor Vehicle #1 (value) Make & Year: _________________ Registration: _________________ 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 You _______________ ________________ Amount Owed to Your Spouse ____________ ____________ American LegalNet, Inc. www.USCourtForms.com 7. State the persons who rely on you or your spouse for support. Name _______________________________ _______________________________ Relationship __________ __________ Age ____ ____ 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. YOUR SPOUSE $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ YOU Rent or home mortgage payment (include lot rented for mobile home) Are real estate taxes 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)): _________________________________________________ Installments 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): _____________________________________________ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $____