::::::: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Index No.Calendar No.Form 6FORM 6. Motion and Declaration for Leave to Proceed in Forma PauperisJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT v. No. THE PEOPLE OF THE STATE OF NEW YORK TOMotion and Declaration for Leave to Proceed in Forma PauperisINSTRUCTIONS: If you do not pay the fee, file this completed form with your petition for review or notice of appeal within 14 days of the date of docketing. 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 docket number, and the question number. Failure to fully answer the questions may result in a denial of the motion.GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofPetitioner/ Appellant hereby moves for leave to proceed in forma pauperis, pursuant to 28 U. S. C. ยง 1915, in this case and submits the following declaration in support thereof: I, ,o'clock in the day ofnoon, and at any recessed in room, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of theam the Petitioner/ Appellant in the above-entitled case. In support of my motion to proceed on appeal without being required to pay the docketing fee, I state that I am unable to pay the fee because of my poverty; that I believe that I am entitled to redress; and that the issues which I desire to present on appeal are the following:Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. , one of the Justices of theCourt in Witness, Honorableday of, 20 County,I further declare that the responses which I have made to the questions and instructions below relating to my ability to pay the docketing fee are true. 1.For both you and your spouse, estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise.(Attorney must sign above and type name below)Attorney(s) forIncome sourceAmount expected during the past 12 monthsAverage monthly amountnext monthSpouseYouSpouseYouEmployment$ $ $ $ Office and P.O. AddressSelf-employment$ $ $ $ Income from real property$ ( such as$ $ $ Telephone No.: Facsimile No.: E-Mail Address:rental income)Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com::::::: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Index No.Calendar No.Form 6FORM 6. Motion and Declaration for Leave to Proceed in Forma Pauperis ( continued)JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Average monthly amountAmount expected during the past 12 monthsnext monthYouSpouseYouSpouseInterest and dividends$ $ $ $ Gifts$ $ $ $ Alimony$ $ $ $ THE PEOPLE OF THE STATE OF NEW YORK TOChild support$ $ $ $ Retirement ( such as$ $ $ $ social security,pensions, annuities, insurance)Disability ( such as social$ $ $ $ security, insuranceGREETINGS:payments)Unemployment payments$ $ $ $ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,Public assistance ( such$ $ $ $ as welfare)located at County ofo'clock in the day ofnoon, and at any recessed in room, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of theOther ( specify) $ $ $ $ Total monthly income:$ $ $ $ 2.List your employment history for the past two years, most recent employer first. ( Gross monthly pay is pay before taxes or other deductions. )Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.EmployerAddressDates ofGross monthly employmentpay , one of the Justices of the Court in Witness, Honorableday of, 20 County, 3.List your spouse 's employment history for the past two years, most recent employer first. ( Gross monthly pay is pay before taxes or other deductions. )(Attorney must sign above and type name below)EmployerAddressGross monthly employmentDates ofpayAttorney(s) for Office and P.O. Address4.Are you presently incarcerated? Yes No If so, 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.Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comMay 1, 2004 Edition::::::: . . . . . . . . . . . . . . . . . . . . .
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