Free Form 04 - Affidavit Accompanying Motion for Permission to Appeal In Forma Pauperis - Federal

Form 4.

Affidavit Accompanying Motion for Permission to Appeal In Forma Pauperis

UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT

Appellant or Petitioner, v. Appellee or Respondent, Case No.

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. sec. 1746; 18 U.S.C. sec. 1621.

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 nore space to answer a question, 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:

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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. Average monthly amount during the past 12 months
Income Source You
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Amount expected next month
You
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Spouse

Spouse

Employment Self-Employment 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:
$

$

$

$

$

$

$

$

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2.

List your employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address
From To From To From To From To $ $ $

Dates of Emplyoment

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
From To From To From To From To $ $ $

Dates of Emplyoment

Gross Monthly Pay

$

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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, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutuional 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 sopuse owns. Do not list clothing and ordinary household furnishing. Home Value Other Real Estate Value

$

$

Motor Vehicle 1: Make & Year

Model

Registration #
$

Value

Motor Vehicle 2: Make & Year

Model

Registration #
$

Value

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Other Assets

Value
$ $ $

6.

State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or your spouse
$ $ $

Amount owed to you

Amount owed to your spouse
$ $ $

7.

State the persons who rely on you or your spouse for support. If a dependent is a minor, list only the initials and not the full name.

Name

Relationship

Age

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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 Spouse

Rent or home-mortgage payment (include lot rented for mobile home) - Are real estate taxes included? No Yes Yes No - Is property insurance included? 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): (name):
$ $ $ $

$ $ $ $ $

$

$ $ $ $

- Department Store

- Motor Vehicle......................................................................................................................... $
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Alimony, maintenance, and support paid to others Regular expenses for the operation of business, profession, or farm (attach detailed statement) Other (specify)

$

$

$ $

$ $ $

Total Monthly Expenses: $

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, describe on an 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. Name Address City Telephone Number (ex., 4153558000) 11. Have you paid--or will you be paying--anyone other than 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

State

Zip Code

If yes, how much? $ If yes, state the attorney's name, address, and telephone number. Name Address City Telephone Number (ex., 4153558000)
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State

Zip Code

12.

Provide any other information that will help explain why you cannot pay the docket fees for your appeal.

13.

State the city and state of your legal residence. City State

Your daytime telephone number (ex., 4153558000) Your age: Your years of schooling:

Last four digits of your Social Security Number (ex.,6789)

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