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Affidavit For Proceeding In Forma Pauperis - Minnesota
| Affidavit For Proceeding In Forma Pauperis Form. This is a Minnesota form and can be used in Tax Court District Court Statewide . |
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STATE OF MINNESOTA TAX COURTCOUNTY OF JUDICIAL DISTRICTTitle of Case: AFFIDAVIT FOR PROCEEDING IN FORMA PAUPERISTax Court Docket/File No.: I request a court order waiving court fees and costs. I believe that I have valid reasons for pursuing thiscivil action. 1. I am a party in this action and in good faith I request an Order to proceed in forma pauperis.2. I am receiving public assistance under one or more of the following programs: SSI and/or MSA (the Supplemental Security Income and Minnesota Supplemental Assistance programs); AFDC (Aid to Families with Dependent Children); Food Stamps; General Assistance or Work Readiness; Medical Assistance or General Assistance; Medical Care; Energy Assistance; and/or Other (specify) .3. I am represented by an attorney, , on behalf of , a civil legal services program or volunteer attorney program, based on indigency. 4. My annual family income before taxes is $ which is less than 125% of the Federal Poverty Line for my family size of members. (NOTE: See Court Administrators Office for a current poverty line schedule.) IF YOU CHECK ANY OF BOXES 2 THROUGH 4 ABOVE, SKIP 5 (a-i) AND SIGN THIS DOCUMENT IN THE PRESENCE OF A NOTARY PUBLIC. 5. I can not support myself and my family and also pay court fees and costs. (If you check this box, you must complete the following Financial Statement.) a. There are minor child(ren) residing with me. b. My net (take home) monthly income is $ . c. The source of my monthly income is . d. I pay $ per month in child care or support. e. I pay $ per month for rent/mortgage payment. f. I own the following property: (1) Cash $ (2) Checking, savings and credit union accounts $ (CONTINUED ON REVERSE SIDE) <<<<<<<<<********>>>>>>>>>>>>> 2 f. Continued: arket value less unpaid (3) Cars, other vehicles (list make, year and equity value [market value less unpaid (a) $ (b) $ (c) $ (4) Real Estate $ (5) Other personal property (jewelry, stocks, bonds, etc. - list separately) (a) $ (b) $ (c) $ g. I am presently $ in debt. h. I am unable to pay the costs and expenses of this proceeding or to give security for such costs and expenses. i. Other factors which support this are: (Explain unusual medical expenses, emergencies or other circumstances to help the judge understand your situation.) Subscribed and sworn to before me this day of , . Signature ADDRESS: PHONE: ( ) Notary Public/Deputy Court Administrator (FOR TAX COURT USE ONLY) TA-00020-01 (01/91)
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