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United States Court of Appeals
FOR THE DISTRICT OF COLUMBIA CIRCUIT

_____________________________ v. _____________________________

USCA No. ____________________

USDC No. ____________________

MOTION FOR LEAVE TO PROCEED ON APPEAL IN FORMA PAUPERIS I, ___________________________________________, declare that I am the 9 appellant/petitioner 9 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. You may continue on the other side of this sheet if necessary.)

Signature ____________________________________________________________ Name of Pro Se Litigant (PRINT) __________________________________________ 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

[USCADC Form 53 (Jul 2007)]

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United States Court of Appeals
FOR THE DISTRICT OF COLUMBIA CIRCUIT

_____________________________ v. _____________________________

USCA No. ____________________

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:

[USCADC Form 53a (Rev. Jul 2007)]

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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. Income source Average monthly amount during the past 12 months You Employment Self-employment $______ $______ Spouse $______ $______ Amount expected next month

You $______ $______

Spouse $______ $______

You 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): _________ $______ $______ $______ $______ $______

Spouse $______ $______ $______ $______ $______

You $______ $______ $______ $______ $______

Spouse $______ $______ $______ $______ $______

$______

$______

$______

$______

$______ $______

$______ $______

$______ $______

$______ $______

$______ $______

$______ $______

$______ $______

$______ $______

Total monthly income: $______

$______

$______

$______

[USCADC Form 53a (Rev. Jul 2007)]

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2. List your employment history for the past two years, 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 for the past two years, 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 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) ____________ ____________ ____________ Other real estate (Value) ____________________ ____________________ ____________________ Motor vehicle #1 ___________(Value) Make & year: ___________________ Model: ________________________ Registration #.__________________

Motor vehicle #2 ___________(Value) Make & year: ___________________ Model: ________________________ Registration #.__________________

Other Assets (Value) _________________ _________________ _________________ -3-

Other Assets (Value) ________________ ________________ ________________

[USCADC Form 53a (Rev. Jul 2007)]

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 by spouse ___________ __________ ___________ __________ ___________ __________ ___________ __________ ___________ __________ ___________ __________

8. State the persons who rely on you or your spouse for support. Name _____________________ _____________________ _____________________ 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 Rent or home-mortgage payment (include lot rented for mobile home) Are real-estate taxes included? Is property insurance included? [ ] Yes [ ] Yes $______ Spouse $______

[ ] No [ ] No You Spouse $______

Utilities (electricity, heating fuel, water, sewer, and telephone) Home maintenance (repairs and upkeep)
[USCADC Form 53a (Rev. Jul 2007)]

$______

$______ -4-

$______

You 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: $______ $______ $______ $______ $______

Spouse $______ $______ $______ $______ $______

$______

$______

$______

$______

$______ $______ $______ $______ $______ $______

$______ $______ $______ $______ $______ $______

$______ $______ $______ $______ $______ $______

$______ $______ $______ $______ $______ $______

$______

$______

$______ $______

$______ $______

[USCADC Form 53a (Rev. Jul 2007)]

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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 docket fees for your appeal.

14. State the address of your legal residence. ___________________________________________________ ___________________________________________________ ___________________________________________________ Your daytime phone number: (____) ________________ Your age: ________ Your years of schooling: _________

[USCADC Form 53a (Rev. Jul 2007)]

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