UNITED STATES COURT OF APPEALS DISTRICT OF COLUMBIA CIRCUIT 333 Constitution Avenue, NW Washington, DC 20001-2866 Phone: 202-216-7000 | Facsimile: 202-219-8530 USCA No. v. USDC No. MOTION FOR LEAVE TO PROCEED ON APPEAL IN FORMA PAUPERIS I, , declare that I am the appellant/petitioner appellee/respondent in the above-entitled proceeding. In support of this motion to proceed on appeal without being required to prepay fees, costs or give security therefor, I state that because of my poverty I am unable to prepay the costs of said proceeding or to give security therefor. My affidavit or sworn statement is attached. I believe I am entitled to relief. The issues that I desire to present on appeal/review are as follows: (Provide a statement of the issues you will present to the court. Attach an additional sheet if necessary.) Signature Name of Pro Se Litigant Address Submit original with a certificate of service to: Clerk of Court United States Court of Appeals for the District of Columbia Circuit E. Barrett Prettyman U.S. Courthouse, Room 5523 333 Constitution Avenue, N.W. Washington, DC 20001 -1USCA Form 31 November 2010 (REVISED) American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES COURT OF APPEALS DISTRICT OF COLUMBIA CIRCUIT 333 Constitution Avenue, NW Washington, DC 20001-2866 Phone: 202-216-7000 | Facsimile: 202-219-8530 USCA No. v. USDC No. AFFIDAVIT ACCOMPANYING MOTION FOR PERMISSION TO APPEAL IN FORMA PAUPERIS ........................................................................................................................................................... Affidavit in Support of Motion Instructions 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.) 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. Signed: Date: My issues on appeal are: -1USCA Form 31 November 2010 (REVISED) American LegalNet, Inc. www.FormsWorkFlow.com 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 Spouse You Spouse Amount expected next month You Spouse Employment Self-employment You Spouse 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- USCA Form 31 November 2010 (REVISED) American LegalNet, Inc. www.FormsWorkFlow.com 2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Dates of employment Address Gross monthly pay 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.) Dates of employment Employer Address 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. Home (Value) Motor Vehicle #1 Other real estate(Value) (Value) Make & Year: Model: Registration #: Motor Vehicle #2 Other Assets (Value) Other Assets (Value) Make & Year: Model: Registration #: -3USCA Form 31 November 2010 (REVISED) American LegalNet, Inc. www.FormsWorkFlow.com 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 every person, business, or organization to whom you or your spouse owes money, the nature of the indebtedness, and the amount owed. Person to whom you or your spouse owe money Nature of indebtedness (e.g., mortgage, credit card) Amount owed by you 8. State the persons who rely on you or your spouse for support. Name [or, if under 18, initials only] Relationship by spouse 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. Spouse You Rent or home-mortgage payment (include lot rented for mobile home) Are real-estate taxes included? Yes No Is property insurance included? Yes No You Spouse Utilities (electricity, heating fuel, water, sewer, and telephone) Home maintenance (repairs and upkeep) -4USCA Form 31 November 2010 (REVISED) American LegalNet, Inc. www.FormsWorkFlow.com You Spouse 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) Other(specify): Total monthly expenses: USCA Form 31 November 2010 (REVISED) -5- American LegalNet, Inc. www.FormsWorkFlow.com 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 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: 12. 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? If yes, how much? If yes, state the person's name, address, and telephone number: 13. Provide any other information that will help explain why you cannot pay the docket fees for your appeal. 14. 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: -6USCA Form 31 November 2010 (REVISED) American LegalNet, Inc. www.FormsWorkFlow.com