Free (PDF) - Colorado

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLORADO
Civil Action No. ,

Plaintiff(s)/Petitioner(s),
v. ,

Defendant(s)/Respondent(s).

MOTION AND AFFIDAVIT FOR LEAVE TO PROCEED ON APPEAL PURSUANT TO 28 U.S.C. § 1915 AND FED. R. APP. P. 24

I request leave to commence this appeal without prepayment of fees or security therefor pursuant to 28 U.S.C. § 1915 and Fed. R. App. P. 24. I also request that the United States pay for a transcript of the record of proceedings, if any, for inclusion in the record on appeal. In support of my requests, I submit the accompanying affidavit and declare that: (1) (2) I am unable to pay such fees or give security therefor. The issues I desire to raise on appeal are:

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (3) (4) (5) I am entitled to redress. I take this appeal in good faith. The appeal is not frivolous and presents a substantial question.

I swear that the responses which I have made to the questions and instructions below relating to my ability to pay the cost of prosecuting the appeal are true.
Rev. 11/04 1

MARITAL STATUS AND DEPENDENTS Single ____ Married ____ Separated ____ Divorced ____ The following individuals are my dependents (Identify minor children by their initials only. Do not include their date of birth.): Name Age Relationship Name Age Relationship Name Age Relationship Name Age Relationship RESIDENCE Street Address: City: Zip Code:

State: Telephone:

EDUCATION What is the highest level of formal education you have received: __________________________ I can speak, read, write, and understand the English language: Yes _____ No _____ EMPLOYMENT If employed at present, complete the following: Name of employer: Address of employer: Telephone number of employer: How long have you been employed by present employer: Income: Monthly $ If self-employed, state your net income: Monthly $ What is the nature of your self-employment? If unemployed at present, complete the following: I have been unemployed since: Name of last employer: Address of last employer: Telephone number of last employer: Salary or hourly wage received from last employer: $ If spouse is employed, complete the following: Name of employer: How long has spouse been employed by present employer: Income: Monthly $ Weekly $ If receiving public assistance (e.g., welfare, unemployment benefits), complete the following: I have been receiving public assistance since: Monthly benefits: $ Weekly benefits: $
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Weekly $ Weekly $

REAL AND PERSONAL PROPERTY Real property: Do you own real property? Yes _____ No ______ If yes, describe: Address: Name(s) on title: Estimated value: $ Amount owed: $ Annual income from real property: $ Personal property: Automobile: Make: Name(s) on registration: Estimated value: $

Model: Amount owed: $

Year:

Cash on hand: Total amount of cash in banks and savings and loan associations: $ Names and addresses of banks and associations:

Other information pertinent to financial status: (Include stocks, bonds, savings bonds, interests in trusts either owned or jointly owned): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ FINANCIAL OBLIGATIONS: Rent on house or apartment: Mortgage on house: Gas bill: Electric bill: Telephone bill: Food: Clothing: Automobile loan: Automobile insurance: Other insurance: Payments to retail merchants: Total owed: Payments on any other outstanding loans or debts: Total owed: Payments to doctors, hospitals, lawyers: Total owed: Maintenance under separation or dissolution agreement:
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MONTHLY PAYMENT: $ $ $ $ $ $ $ $ $ $ $

$ $

$

Child support: Other Payments: Describe: Describe: Describe: Describe: Total monthly payments:

$ $ $ $ $ $

Signature Name Street Address City Telephone Number Date: Signature of Affiant State Zip Code

SUBSCRIBED AND SWORN TO BEFORE ME THIS ____ day of _____________________, 20____

Notary Public Address My commission expires:_________________________

Rev. 11/04

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