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Affidavit To Accompany Motion For Leave To Appeal In Forma Pauperis - Nebraska
| Affidavit To Accompany Motion For Leave To Appeal In Forma Pauperis Form. This is a Nebraska form and can be used in General District Court Federal . |
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AFFIDAVIT TO ACCOMPANY MOTION FOR LEAVE TO APPEAL IN FORMA PAUPERIS United States District Court For the District of Nebraska________________________, ) 8:___CV____________Plaintiff ) ) v. ) )_________________________ ) )_________________________ ) Defendant Affidavit in Support of Motion to Proceed on Appeal in Forma Pauperis I, _____________________________ being first duly sworn,depose and say that I am _________________________, in the above-entitled case; that in support of my motion to proceed on appealwithout being required to prepay fees, costs or give securitytherefore, I state that because of my poverty I am unable to paythe costs of said proceeding or to give security therefore; thatI believe I am entitled to redress; and that the issues which Idesire to present on appeal are the following: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<<<<<<<<<********>>>>>>>>>>>>> 2 I further swear that the responses which I have made to thequestions and instructions below relating to my ability to paythe cost of prosecuting the appeal are true.1. Are you presently employed? a. If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer. ____________________________________________________ ____________________________________________________ b. If the answer is no, state the date of your last employment and the amount of the salary and wages per month which you received. ____________________________________________________ ____________________________________________________2. Have you received within the past twelve months any incomefrom a business, profession or other form of self-employment, orin the form of rent payments, interest, dividends, or othersource? a. If the answer is yes, describe each source of income, and state the amount received from each during the past twelve months. _____________________________________________________ _____________________________________________________3. Do you own any cash or checking or savings account? a. If the answer is yes, state the total value of the items owned. _____________________________________________________ _____________________________________________________<<<<<<<<<********>>>>>>>>>>>>> 34. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? a. If the answer is yes, describe the property and state the approximate value. _____________________________________________________ _____________________________________________________5. List the persons who are dependent upon you for support andstate your relationship to those persons. ________________________________________________________________________________________________________________________________ I understand that a false statement or answer to any questions in this affidavit will subject me to penalties for perjury. ___________________________/s/SUBSCRIBED AND SWORN TO before me this _____ day of ____________,_____. Let the applicant proceed without prepayment of costs or fees orthe necessity of giving security therefore. _____________________________ U.S. District Judge
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