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Motion And Affidavit For Permission To Appeal In Forma Pauperis 4 - Maryland
| Motion And Affidavit For Permission To Appeal In Forma Pauperis Form. This is a Maryland form and can be used in Pro Se District Court Federal . |
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Form 4. Motion and Affidavit for Permission to Appeal In Forma Pauperis Motion and Affidavit for Permission to Appeal In Forma Pauperis v. Appeal No. District Court or Agency No. Affidavit in Support of Motion Instructions I swear or affirm under penalty of perjury that, because ofComplete all questions in this application and then sign my poverty, I cannot prepay the docket fees of my appeal it. Do not leave any blanks: if the answer to a question is or post a bond for them. I believe I am entitled to redress.0, none, or not applicable (N/A), write in that I swear or affirm under penalty of perjury under United response. If you need more space to answer a question or States laws that my answers on this form are true and to explain your answer, attach a separate sheet of paper correct. (28 U.S.C. 1746; 18 U.S.C. 1621.) identified with your name, your cases docket number, and the question number. __________________________________________ __________________________________________ __ __ Signature Date My issues on appeal are: 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. Average monthly amount during Income source Amount expected next month the past 12 months You Spouse You Spouse Employment $ $ $ $ Self-employment $ $ $ $ Income from real property (such as rental income) $ $ $ $ Interest and dividends $ $ $ $ Gifts $ $ $ $ Alimony $ $ $ $ Child support $ $ $ $ (D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis Page 1 of 5<<<<<<<<<********>>>>>>>>>>>>> 2 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: $ $ $ $ 2. List your employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Dates of Gross Employer Address Employment Monthly Pay $ $ $ 3. List your spouses employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Dates of Gross Employer Address Employment Monthly Pay $ $ $ 4. How much cash do you and your spouse have? $___________________________________ Below, state any money you or your spouse have in bank accounts or in any other financial institution. Amount you Amount your Financial institution Type of account have spouse has $ $ $ $ $ $ If you are a prisoner, 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. 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. (D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis Page 2 of 5<<<<<<<<<********>>>>>>>>>>>>> 3 Home (Value) Other Real Estate (Value) Motor Vehicle #1 (Value) Make and year: Model: Registration No: Home (Value) Other Real Estate (Value) Motor Vehicle #2 (Value) Make and year: Model: Registration No: 6. State every person, business, or organization owing you or your spouse money, and the amount owed. Amount owed Amount owed Person(s) owing you or your spouse money to you to your spouse $ $ $ $ $ $ 7. State the persons who rely on you or your spouse for support. Name Relationship Age8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Amount expected next month Expenses You Spouse 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, heating fuel, water, sewer, and telephone)$ $ Home maintenance (repairs and upkeep) $ $ Food $ $ Clothing $ $ Laundry and Dry Cleaning $ $ Medical and dental expenses $ $ (D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis Page 3 of 5<<<<<<<<<********>>>>>>>>>>>>> 4 Transportation (not including motor vehicle payments) $ $ Recreation, entertainment, newspapers, magazines, etc. $ $ Insurance (not deducted from wages or included in Mortgage payments): Homeowners or renters $ $ Life $ $ Health $ $ Motor Vehicle $ $ Other: $ $ Taxes (not deducted from wages or included in Mortgage payments) (specify): $ $ Installment payments Motor Vehicle $ $ Credit card (name): $ $ Department Store (name): $ $ Other: $ $ Alimony, maintenance, and support paid to others $ $ Regular expenses for operation of business, profession, or farm (attach detailed statement) $ $ Other (specify): $ $ Total monthly expenses: $ $ 9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? YES NO If yes, describe on an attached sheet. 10. Have you paid - or will you be paying- an attorney any money for services in connection with this case, including the completion of this form? YES NO If yes, how much? $ If yes, state the attorneys name, address, and telephone number: (D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis Page 4 of 5<<<<<<<<<********>>>>>>>>>>>>> 511. Have you paid or will you be paying anyone other than an attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion of this form? YES NO If yes, how much? $ If yes, state the persons name, address, and telephone number: 12. Provide any other information that will help explain why you cannot pay the docket fees for your appeal.13. State the address of your legal residence. Your daytime phone number: Your age: Your years of schooling: Your social-security number: (D. Md. Rev. 4/2001) Motion and Affidavit for Permission to Appeal In Forma Pauperis Page 5 of 5
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