Official Federal Forms > Circuit Court Of Appeals > 11th Circuit Court Of Appeals
Motion For Permission To Appeal In Forma Pauperis And Affidavit - Official Federal Forms
| Motion For Permission To Appeal In Forma Pauperis And Affidavit Form. This is a national form and can be used in 11th Circuit Court Of Appeals Circuit Court Of Appeals . |
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Motion for Permission to Appeal In Forma Pauperis and Affidavit United States Court of Appeals for the Eleventh Circuit v. Court of Appeals No. ______________ District Court No. _________________ 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: _______________________________________ 1. My issues on appeal are: _____________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Rev.: 3/13 American LegalNet, Inc. www.FormsWorkFlow.com 2. 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 during the past 12 months You Spouse $ ________ $ ________ $ ________ Amount expected next month You $ ________ $ ________ $ ________ Spouse $ ________ $ ________ $ ________ Income Source 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): __________________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ _________ $ _________ $ _________ $ _________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ Total monthly income: 3. $ _________ $ ________ $ ________ $ ________ 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 _________________________ _________________________ _________________________ 4. ________________________ ________________________ ________________________ ___________________ ____________________ _____________________ ______________ ______________ ______________ List your spouse's employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) _________________________ ________________________ ____________________ ________________ _________________________ 5. ________________________ ____________________ ________________ How much cash do you and your spouse have? $_____________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com 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. 6. 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) _______________________ Motor Vehicle #1 (Value) Make & Year: ______________________________ _____________________ _______________________ Model: ____________________________________ _____________________ _______________________ Registration #: ______________________________ Other Assets(Value) _____________________ _____________________ _____________________ 7. Other Assets (Value) _______________________ _______________________ _______________________ Motor Vehicle #2 (Value) Make & Year ___________________________ Model: _______________________________ Registration #: __________________________ Home (Value) _____________________ State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or your spouse money _________________________________ _________________________________ _________________________________ Amount owed to you ____________________________ ___
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