Free Corel Office Document - Maryland

Form 4.

Motion and Affidavit for Permission to Appeal In Forma Pauperis

Motion and Affidavit for Permission to Appeal In Forma Pauperis
v. Appeal No. District Court or Agency 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. § 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 "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. ____________________________________________ Date

____________________________________________ Signature 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. Average monthly amount Income source Amount expected next month during the past 12 months You Spouse $ $ $ $ $ $ $ $ $ $ $ $ $ $ You $ $ $ $ $ $ $ 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

$ $ $ $ $ $ $

$

$

$

$

(D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis

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Disability (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.) Dates of Gross Employer Address Employment Monthly Pay $ $ $

3.

List your spouse's employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Dates of Gross Employer Address Employment 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. Amount you Amount your Financial institution Type of account have 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 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 and year: Model:

(D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis

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Registration No: Home (Value) Other Real Estate (Value) Motor Vehicle #2 (Value) Make and year: Model: Registration No: 6. State every person, business, or organization owing you or your spouse money, and the amount owed. Amount owed Amount owed Person(s) owing you or your spouse money to your to you 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. Amount expected next month Expenses You Spouse Rent or home-mortgage payment (include lot rented for mobile home) Are real-estate taxes included? YES NO Is property insurance 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.

$ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $

(D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis

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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: 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?
(D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis

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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:

(D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis

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