Free New a-11 Form - Oklahoma

UNITED STATES COURT OF APPEALS FOR THE TENTH CIRCUIT

Case No. __________________

Plaintiff/Petitioner - Appellant, v.

Motion for Leave to Proceed on Appeal Without Prepayment of Costs or Fees

Defendant/Respondent - Appellee.

I, _________________________________________, the petitioner/appellant in the captioned case move this court for leave to proceed in forma pauperis.

Your motion for leave to proceed on appeal without prepayment of costs or fees and/or application for a certificate of appealability will be evaluated by the court using these standards: Leave to Proceed Without Prepayment of Costs or Fees. You must meet all of the requirements of the Prisoner Litigation Reform Act, Pub. L. No. 104-134, 110 Stat. 1321 (Apr. 26, 1996); 28 U.S.C. § 1915. This includes submitting the certified statement of trust account and authorization to deduct funds attached to this form. The forms will not be considered unless they are complete.

FINANCIAL DECLARATION

Affidavit to Accompany Motion for Permission to Appeal in Forma Pauperis

I swear or affirm under penalty of perjury that because of my poverty I am unable to pay the docket fees of my appeal or to post a bond for them. I believe I am entitled to a different result than that reached in the district court. I further swear or affirm under penalty of perjury that the responses which I have made to the questions and instructions below relating to my ability to pay the fees for my appeal are true. Instructions. Please complete all questions in this application and then sign it on the last page. If the answer to any question is "0" or "none," or the question is "not applicable", so indicate by writing "0", "none", or "not applicable (N/A)". If additional space is needed to answer any question or to explain your answer to any question, please use and attach a separate sheet of paper identified with your name, the docket number of your case and the number of the question. My issues on appeal are:

1. Are you or your spouse currently employed?

Yes _____

No _____

2. If you or your spouse are currently employed, state the name and address of your employer, the length of your employment with that employer, and your monthly gross pay. Gross pay is pay before any taxes or other deductions are taken. If you have more than one employer, please provide the information requested below about the other employer(s) on a separate sheet of paper and attach it to this application.

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Yourself: Name and Address of Employer _________________________________ _________________________________ _________________________________ Length of Employment _____ ______ Years Months Monthly Gross Pay $____________

Your Spouse: Name and Address of Employer _________________________________ _________________________________ _________________________________ Length of Employment _____ ______ Years Months Monthly Gross Pay $____________

3. If you are currently unemployed, state the date of your last employment and your monthly gross pay during your last month of employment. Gross pay is pay before any taxes or other deductions are taken. Date of last employment (Month/Year) for yourself _______________; spouse _____________ Monthly gross pay during last month of employment $____________ 4. State whether you or your spouse have received money from any of the following sources during the past twelve months, and, if so, the average monthly amount from that source. Adjust any money that was received weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. Did you receive money from any of the following sources during the past 12 months? Average monthly amount during past 12 months for you and your spouse if applicable. You Self-employment Income from real property (such as rental income) Interest and dividends Gifts Alimony Child Support Y/N ___ Y/N ___ Y/N ___ Y/N ___ Y/N ___ Y/N ___ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ Spouse $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ Amount expected next month You $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ Spouse $ _______ $ _______ $ _______ $ _______ $ _______ $ _______

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Retirement income from sources such as social security, private pensions, annuities, or insurance policies Disability payments such as social security, other state or federal government, or insurance payments Unemployment payments

Y/N ___

$ _______

$ _______

$ _______

$ _______

Y/N ___ Y/N ___

$ _______ $ _______ $ _______ $ _______

$ _______ $ _______ $ _______ $ _______ $ _______

$ _______ $ _______ $ _______ $ _______ $ _______

$ _______ $ _______ $ _______ $ _______ $ _______

Public assistance payments such as welfare payments Y/N ___ Other sources of money (specify: ____________________) Y/N ___ TOTAL

5. State the amount of cash you and your spouse have: $ ___________

State below any money you or your spouse have in savings, checking, or other accounts in a bank or other financial institution. Bank or Other Financial Institution: Type of Account such as savings, checking, or CD: ________________ ________________ ________________ Amount you have: $ _________ $ _________ $ _________ Amount your spouse has: $ _________ $ _________ $ _________

__________________________________ __________________________________ __________________________________

If you have funds in a prison or other similar institutional account, the Certified Statement of Institutional Account for the Past Six Months at the end of this form must be completed by the institution.

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6. State below the assets owned by you and your spouse. Do not list ordinary household furnishings and clothing. Home Address: _________________________________ _________________________________ Other real estate Address: _________________________________ _________________________________ Motor vehicle Model/Year: ________________________ Motor vehicle Model/Year: ________________________ Other Description: ______________________ _________________________________ Value: $ _________ Amount owed on mortgages and liens: $ _________ Value: $ _________ Amount owed on mortgages and liens: $ _________ Value: $ _________ Amount owed: $ _________ Value: $ _________ Amount owed: $ _________ Value: $ ________ Amount owed: $ _________

7. State below any person, business, organization, or governmental unit that owes you or your spouse money and the amount that is owed. Name of Person, Business, or Organization Amount Owed that Owes You or Your Spouse Money __________________________________ __________________________________ You: $ _________ $ _________ Amount Owed Your Spouse: $ _________ $ _________

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8. State the individuals who rely on you and your spouse for support. Indicate their relationship to you, their age, and whether they live with you. Name Relationship Age Does this person live with you? ___________________ ________________ _________ Yes _____ No _____

___________________

________________

_________

Yes _____

No _____

___________________

________________

_________

Yes _____

No _____

___________________

________________

_________

Yes _____

No _____

9. Complete this question by estimating the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. You 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 and heating fuel Water and sewer Telephone Other ___________________ Home maintenance (Repairs and upkeep) Food Clothing Laundry and dry cleaning Medical and dental expenses Transportation (not including car payments)
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Spouse $ ________

$ ________

$ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________

$ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ Page 6

Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees 1/04

Recreation, clubs and entertainment, newspapers, magazines, etc. $ ________ Charitable contributions Insurance (not deducted from wages or included in home mortgage payments) Homeowner's or renter's Life Health Auto Other ___________________ Taxes (not deducted from wages or included in home mortgage payments) (specify) __________________________________ Installment payments Auto: Credit Card: (name) ____________________ Department Store: (name) ________________________ Other ___________________ Other ___________________ Alimony, maintenance, and support paid to others Payments for support of additional dependents not living at your home Regular expenses from operation of business, profession, or farm (attach detailed statement) Other ___________________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________

$ ________ $ ________

$ ________ $ ________ $ ________ $ ________ $ ________

$ ________

$ ________ $ ________ $ ________ $ ________ $ ________ $ ________

$ ________

$ ________ $ ________

TOTAL MONTHLY EXPENSES

$ ________

$ ________

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10. Do you expect any major changes to your monthly income or expenses during the next four months? Yes _____ If yes, describe. No _____

11. Have you paid an attorney any money for services in connection with this case, including the completion of this form? Yes _____ If yes, how much? $ _________ No _____

If yes, provide the name, address, and telephone number of the attorney: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Have you promised to pay or do you anticipate paying an attorney any money for services in connection with this case, including the completion of this form? Yes _____ If yes, how much? $ _________ If yes, provide the name, address, and telephone number of the attorney: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 12. Have you paid anyone other than an attorney (such as a paralegal, typing service, or another person) any money for services in connection with this case, including the completion of this form? Yes _____ No _____ No _____

If yes, how much? $ _________ If yes, provide the name, address, and telephone number of the person or service: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

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13. Have you promised to pay or do you anticipate paying anyone other than an attorney (such as a paralegal, typing service, or another person) any money for services in connection with this case, including the completion of this form? Yes _____ If yes, how much? $ __________ If yes, provide the name, address, and telephone number of the person or service: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ No _____

14. How much can you pay each month toward the docket fee for your appeal. $ ______________

15. Please provide any other information that helps to explain why you are unable to pay the docket fees for your appeal.

16. State the address of your legal residence: ___________________________________________________ ___________________________________________________ ___________________________________________________

Your daytime phone number: (______)___________________ Your age: __________________ Years of schooling: _____________________ Your social security number: ____________________

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I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA THAT THE FOREGOING IS TRUE AND CORRECT. 28 U.S.C. § 1746, 18 U.S.C. § 1621.

Date:

Signature:

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ADDENDUM TO FINANCIAL DECLARATION

THIS ADDENDUM MUST BE COMPLETED BY ANYONE WHO IS A PRISONER AS DEFINED BY 28 U.S.C § 1915(h) Prisoner Name ____________________________

Appeal Number ___________________________

Facility __________________________________

PLEASE NOTE THAT SECTION A AND B OF THIS PART OF THE FORM BOTH MUST BE COMPLETED IN ORDER FOR US TO PROCESS THIS APPEAL. FAILURE TO COMPLY MAY BE GROUNDS FOR DISMISSAL.

Section A: Certified Trust Fund Account Statement

I certify that the prisoner named below has had an average monthly balance of _________ for the previous six month period. Attached to this document is a certified copy of the prisoner's trust fund account statement for the past six months. Prisoner's Name _____________________________________ Signature of Authorized Officer ________________________ Date ______________________________________________

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Section B: AUTHORIZATION

I, __________________________, request and authorize the agency [print your name] holding me in custody to send to the clerk of the United States Court of Appeals for the Tenth Circuit a certified copy of the statement for the past six months of my trust account or institutional equivalent at the institution where I am incarcerated. I further request and authorize the agency holding me in custody to calculate and disburse funds from my trust account or institutional equivalent in the amounts specified by 28 U.S.C. § 1915(b). This authorization is furnished in connection with this appeal and I understand that the total fee is due regardless of the outcome of the case. I understand the fee is $455 in an appeal or $450 in an original proceeding or petition for review.

Prisoner Name (please print) ____________________________ Signature ___________________________________________

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CERTIFICATE OF SERVICE

I hereby certify that on ____________________________ I sent a copy of [date] the foregoing Motion for Leave to Proceed on Appeal without Prepayment of Costs of Fees, to: _____________________________________, at ___________________________ ___________________________________________________________________ ______________________________________________, the last known address, by way of United States mail or courier.

_____________________________________ _____________________________ Date Signature

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