Free Form 4.  Affidavit With Motion to Proceed In Forma Pauperis - Federal

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.

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 $ _________ $ _________ $ _________

____________________________ ____________________________ ____________________________

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 ____________ ____________

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): _____________________________________________ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______ $______

9.

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, how much $______. If yes, state the attorney's name address, and telephone number. Name: Address: Telephone: _________________________________________________________ _________________________________________________________ _________________________________________________________

10.

Have you paid­or will you be paying­an 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. Name: Address: Telephone: __________________________________________________________ __________________________________________________________ __________________________________________________________

11.

Have you paid­or will you be paying­anyone 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. Name: Address: Telephone: __________________________________________________________ __________________________________________________________ __________________________________________________________

12.

Provide any other information that will help explain why you cannot pay the docket fees for your appeal. State the address of your legal residence: ____________________________________ _____________________________________________________________________ Your daytime phone number: ___________________ Your Age: ___________________ Your years of schooling: ___________________ Your Social Security Number: ___________________

13.