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Affidavit Accompanying Motion For Permission To Appeal In Forma Pauperis - Arizona
| Affidavit Accompanying Motion For Permission To Appeal In Forma Pauperis Form. This is a Arizona form and can be used in District Court Federal . |
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Form 4. Affidavit Accompanying Motion for Permission to Appeal In Forma Pauperis United States District Court for District of A.B., Plaintiff v. C.D., Defendant Case No.: ________________________________ Affidavit in Support of Motion I swear or affirm under penalty of perjury that, because of my poverty, I cannot prepay the docket fees of my appeal or post a bond for them. I believe I am entitled to redress. I swear or affirm under penalty of perjury under United States laws that my answers on this form are true and correct. (28 U.S.C. § 1746; 18 U.S.C § 1621.) Instructions 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's docket number, and the question number. Date: _______________________ Signed: My issues on appeal are: (e) 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. -1- American LegalNet, Inc. www.USCourtForms.com Average monthly amount during the past 12 months Income Source 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: $ $ $ $ $ $ $ $ You $ $ $ $ $ $ $ $ Spouse Amount expected next month You $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Spouse $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 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 -2- American LegalNet, Inc. www.USCourtForms.com 3. List your spouse's 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 Institution Type 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 furnishing. Home Value Other real estate Value Motor Vehicle 1 Value Make & Year Model Registration # Motor Vehicle 2 Value Make & Year Model Registration # -3- American LegalNet, Inc. www.USCourtForms.com Other Assets Value 6. State every person, business, or organization owing you of your spouse money, and the amount owed. Person owing you or your spouse Amount owed to you Amount owed to your spouse 7. State the persons who rely on you or your spouse for support. Name Relationship Age 8. 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 are. You $ Your 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 & upkeep) Food Clothing Laundry and dry-cleaning Medical and dental expenses Transportation (not including motor vehicle payments) Recreation, entertainment, newspapers, magazines, etc. -4- American LegalNet, Inc. www.USCourtForms.com Insurance (not deducted from wages or included in Mortgage payments) · Homeowner's or renter's · 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 (attache 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 attorney's name, address, and telephone number. -5- American LegalNet, Inc. www.USCourtForms.com 11. 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 If yes, how much? $ If yes, state the person's name, address, and telephone number. ____________ No 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: -6- American LegalNet, Inc. www.USCourtForms.com
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