Form 6 FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT ____________________________ v. ____________________________ No. _______ Motion and Declaration for Leave to Proceed in Forma Pauperis INSTRUCTIONS: If you do not pay the fee, file this completed form with your petition for review or notice of appeal within 14 days of the date of docketing. 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 docket number, and the question number. Failure to fully answer the questions may result in a denial of the motion. Petitioner/Appellant hereby moves for leave to proceed in forma pauperis, pursuant to 28 U.S.C. § 1915, in this case and submits the following declaration in support thereof: I, ________________________________________, am the Petitioner/Appellant in the above-entitled case. In support of my motion to proceed on appeal without being required to pay the docketing fee, I state that I am unable to pay the fee because of my poverty; that I believe that I am entitled to redress; and that the issues which I desire to present on appeal are the following: _____________________________________________________________________________ I further declare that the responses which I have made to the questions and instructions below relating to my ability to pay the docketing fee are true. 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 Amount expected next month You Spouse You Spouse Employment $_______ $_______ $_______ $_______ Self-employment $_______ $_______ $_______ $_______ Income from real property (such as rental income) 112 Average monthly amount during the past 12 months $_______ $_______ $_______ $_______ American LegalNet, Inc. www.FormsWorkflow.com Form 6 FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis (continued) Average monthly amount during the past 12 months Amount expected next month You Spouse You Spouse 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 pay before taxes or other deductions.) Employer Address Dates of employment Gross monthly pay _________________ __________________ __________________ ___________________ _________________ __________________ __________________ ___________________ _________________ __________________ __________________ ___________________ 3. List your spouse’s employment history for the past two years, most recent employer first. (Gross monthly pay is pay before taxes or other deductions.) Employer Address Dates of employment Gross monthly pay _________________ __________________ __________________ ___________________ _________________ __________________ __________________ ___________________ _________________ __________________ __________________ ___________________ 4. Are you presently incarcerated? _____Yes _____No If so, 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. 113 American LegalNet, Inc. www.FormsWorkflow.com Form 6 FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis (continued) 5. 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. State the average monthly balance. Financial institution Type of account Amount you have Amount your spouse has ______________________ ______________________ _________________ _________________ $_______________ $_______________ $______________ $______________ 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) ______________________ _________________________ Other assets (Value) _________________________ ______________________ _________________________ _________________________ ______________________ _________________________ _________________________ Other assets (Value) Motor vehicle #1 Make, model & year: Motor vehicle #2 Make, model & year: ______________________ _________________________ Value: _________________________ Value: ______________________ _________________________ Registration #: _________________________ Registration #: ______________________ _________________________ _________________________ 7. State every person, business, or organization owing you or your spouse money, and the amount owed: Person, business or organization owing you or your spouse money Amount owed to you Amount owed to your spouse _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ 114 American LegalNet, Inc. www.FormsWorkflow.com Form 6 FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis (continued) 8. State the persons who rely on you or your spouse for support: Initials of Person 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 $__________ $__________ 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. $__________ $__________ Homeowner’s or renter’s $__________ $__________ Life $__________ $__________ Health $__________ $__________ Motor vehicle $__________ $__________ Other: _____________________ $__________ $__________ $__________ $__________ Rent or home mortgage payment (include lot rented for mobile home) Are real estate taxes included? ___Yes ___No Is property insurance included? ___Yes ___No Insurance (not deducted from wages or included in mortgage payments) Taxes (not deducted from wages or included in mortgage payments) (specify): __________________ 115 American LegalNet, Inc. www.FormsWorkflow.com Form 6 FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis (continued) You Your spouse Motor vehicle $__________ $__________ Credit card (name): ______________ $__________ $__________ Department store (name): ______________ $__________ $__________ Other: _____________________ $__________ $__________ Alimony, maintenance, and support paid to others $__________ $__________ Regular expenses for operation of business, $__________ $__________ $__________ $__________ $__________ $__________ Installment payments 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 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? ___Yes ___No 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 docketing fees for your appeal or petition for review. __________________________________________________________________ __________________________________________________________________ 116 American LegalNet, Inc. www.FormsWorkflow.com Form 6 FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis (continued) 14. Have you ever filed a motion for leave to proceed in forma pauperis in any other case in this court? ___Yes ___No If yes, state the name and docket number of that case. __________________________________________________________________ 15. State the address of your legal residence: __________________________________________________________________ __________________________________________________________________ Your daytime phone number: ( ) ____________________________________ Your age: ________________ Your years of schooling: ___________________ __________________________________________________________________ You must sign and date the declaration under penalty of perjury. DECLARATION UNDER PENALTY OF PERJURY I declare under penalty of perjury, under the laws of the United States, that my answer on this form are true and correct. _____________________ Date _________________________________________ Petitioner’s/Appellant’s signature cc: ___________________________________ ORDER OF THE COURT The motion to proceed in forma pauperis is DENIED. The docketing fee must be paid within 14 days. The motion to proceed in forma pauperis is GRANTED. Let the applicant proceed without prepayment of the docketing fee. _____________________ __________ Circuit Judge Date _____________________ _____________ Circuit Judge or Clerk Date Effective May 1, 2008 117 American LegalNet, Inc. www.FormsWorkflow.com