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Plaintiff/Petitioner

vs.

Affidavit for Proceeding In Forma Pauperis (Inmate) (Minn. Stat. §§ 563.01, 563.02)

Defendant/Respondent STATE OF MINNESOTA COUNTY OF (County where Affidavit signed) ) ) SS )

1. I am a party in this action. I am not represented by counsel, I have been convicted of a felony and I am committed to the custody of the Commissioner of Corrections. I am either confined in a state correctional facility or I have been released from a state correctional facility under section Minn. Stat. § 244.065 or 244.07. 2. I believe I have valid reasons for pursuing this action. In good faith, I request an order waiving court fees and costs. My pleadings (the Petition, Complaint, Answer, Appeal or other pleading) are attached. NOTE: If you are the person bringing the case, known as the plaintiff, the statute requires you provide the court with a copy of the Complaint before serving the complaint on the opposing party. 3. The following information is required. You must complete each section. a. I have the following dependents: b. My net (take home) monthly income is $ c. The source of my monthly income is d. If available to you, your spouse's net (take home) monthly income is $ e. I pay $ f. I pay $ per month in child care support. per month for rent/mortgage payment. .

g. I own the following property: 1) Cash $ 2) Checking, savings and credit union accounts $ 3) Cars, other vehicles [list make, year, and equity value (market value minus unpaid loans) for each] a) $

IFP201

State

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Rev 10/05

www.courts.state.mn.us/forms

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b) 4) Real estate a) b)

$

$ $

5) Other personal property (jewelry, stock, bonds, etc. ­ list separately) a) b) h. I am presently $ ______________________ in debt. i. I have the following monthly expenses: $ $

j. Other factors which support this are: (explain unusual medical expenses, emergencies or other circumstances to help the judge understand your situation):

6.

I have exhausted the inmate complaint procedure developed by the Commissioner of Corrections before commencing this action against the Department of Corrections. My claim is not substantially similar to a previous claim brought against the same party, arising from the same facts, and which resulted in an adjudication on the merits. My full name is the following other names: and I have been known by

7.

8.

9.

I have attached a copy of my most recent monthly statement showing the balance in my inmate account. I authorize the Court to obtain at any time during the pendency of this action a current statement of the balance of my inmate account. NOTE: An inmate who has funds in an inmate account may only proceed as a plaintiff in a civil action by paying either the applicable court filing fee or 50% of the balance in the inmate account, whichever is less. If 50% of balance of the inmate account is used to commence the civil action, the Commissioner of Corrections will continue to draw money out of the inmate account until the filing fee is paid in full.
Signature (Sign only in front of notary public or court administrator.)

Dated: Name: Sworn/affirmed before me this day of
Notary Public \ Deputy Court Administrator

Address: , . City/State/Zip: Telephone:

IFP201

State

ENG

Rev 10/05

www.courts.state.mn.us/forms

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