Free IFP Appeal - Florida

Motion for Permission to Appeal In Forma Pauperis and Affidavit
United States Court of Appeals for the Eleventh Circuit Court of Appeals No. ________________________ District Court No. ___________________________

v.

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 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. 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. § 1746; 18 U.S.C. § 1621.) Date: _______________________________ Signed: _______________________________________

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 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 Income from real property (such as rental income) Interests 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 $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ Amount expected next month You $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ Spouse $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________

Total monthly income:

$ _________

$ ________

$ ________

$ ________

(Rev. 12/98)

2.

List your employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Address ________________________ ________________________ ________________________ Dates of Employment ____________________ ____________________ _____________________ Gross Monthly Pay ___________________ ___________________ ___________________

Employer _________________________ _________________________ _________________________ 3.

List your spouse's employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) _________________________ ________________________ ____________________ ___________________ _________________________ _________________________ 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. Other Real Estate (Value) _______________________ _______________________ _______________________ Other Assets (Value) _______________________ _______________________ _______________________ Motor Vehicle #1 (Value) Make & Year: ______________________________ Model: ____________________________________ Registration #: ______________________________ Motor Vehicle #2 (Value) Make & Year: ______________________________ Model: ____________________________________ Registration #: ______________________________

Home (Value) _____________________ _____________________ _____________________ Other Assets(Value) _____________________ _____________________ _____________________ 6.

State every person, business, or organization owing you or your spouse money, and the amount owed. Amount owed to you ____________________________ ____________________________ ____________________________ Amount owed to your spouse _________________________ _________________________ _________________________

Person owing you or your spouse money _________________________________ _________________________________ _________________________________

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7. State the persons who rely on your or your spouse for support. Name Relationship _____________________________ _____________________________ _____________________________ 8. _________________________ _________________________ _________________________

Age _________________________ _________________________ _________________________

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 $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________

For home-mortgage payment (include lot rented for mobile home) Are real-estate taxes included? Is property insurance included?

$ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ _________ $ __________

! Yes ! No ! 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): _______________________________ 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

$ __________

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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:

11. 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:

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

13. State the address of your legal residence.

Your daytime phone number: (_______) ____________________________________ Your age: ___________________ Your years of schooling: _____________________ Your Social Security number: _____________________________________________

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