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Affidavit Accompanying Motion For Permission To Appeal In Forma Pauperis 4 - Official Federal Forms
| Affidavit Accompanying Motion For Permission To Appeal In Forma Pauperis Form. This is a national form and can be used in 6th Circuit Court Of Appeals Circuit Court Of Appeals . |
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FORM 4. AF FI DAVIT ACC OMP ANYI NG MOTION FOR PERM IS SI ON TO APPE AL IN FORM A PAUPERI S United States Court of Appeals for the Sixth Circuit A. B. Plaintiff ] ] v. ] Case No. ______________________ ] C. D., Defendant ] Affidavit in Support of Motion Instructions I swear or affirm under penalty of perjury Complete all questions in this application that, because of my poverty, I cannot prepay and then sign it. Do not leave any blanks: if the docket fees of my appeal or post a bond the answer to a question is "0," "none," or for them. I believe I am entitled to redress. "not applicable (N/A)," write that response. I swear or affirm under penalty of perjury If you need more space to answer a question under United States laws that my answers on or to explain your answer, attach a separate this form are true and correct. (28 U.S.C. sheet of paper identified with your name, 1746; 18 U.S.C. 1621.) your cases docket number, and the question number. Signed: Date: My issues on appeal are: American LegalNet, Inc. www.USCourtForms.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. Income source Av erage monthly Amount expected amount during the next month 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 $____ $____ $____ $____ 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.) Employer Address Dates of Employment Gross monthly pay ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 33. List your spouses employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of Employment Gross 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. Financial InstitutionType of Account Amount you have Amount your 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. Home (Value) Other real estate (Value) Motor Vehicle #1 (Value) __________________ __________________ Make & year:__________________ __________________ __________________ Model: _______________________ __________________ __________________ Registration #__________________ American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4Motor Vehicle #2 (Value) Other assets (Value) Other assets (Value) Make & year: __________________ __________________ __________________ Model: _______________________ __________________ __________________ Registration # __________________ __________________ __________________ 6. State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or your spouse moneyAmount owed to youAmount owed to your spouse _________________________________ __________________________________________ _________________________________ __________________________________________ ___________________________________________________________________________ 7. State the persons who rely on you or your spouse for support. Name Relationship Age _______________________ ______________________________________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 58. 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. You Your Spouse Rent or home-mortgage payment (including 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 $ ____ $ ____ Transportation (not including motor vehicle expenses $ ____ $ ____ Recreation, entertainment, newspapers, magazines, etc. $ ____ $ ___
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