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Form 4 Affidavit Accompanying Motion For Permission To Appeal In Forma Pauperis 4 - Official Federal Forms
| Form 4 Affidavit Accompanying Motion For Permission To Appeal In Forma Pauperis Form. This is a national form and can be used in 9th Circuit Court Of Appeals Circuit Court Of Appeals . |
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Form 4. Affidavit Accompanying Motion for Permission to Appeal In Forma Pauperis UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT Appellant or Petitioner, v. Appellee or Respondent, 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. sec. 1746; 18 U.S.C. sec. 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 nore space to answer a question, attach a separate sheet of paper identified with your name, your case's docket number, and the question number. Signed: Date: My issues on appeal are: -1- American LegalNet, Inc. www.FormsWorkflow.com 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 the past 12 months Income Source Employment Self-Employment Income from real property (such as rental income) Interest and Dividends Gifts Alimony Child Support $ $ Amount expected next month You $ $ $ $ $ $ You $ $ Spouse Spouse $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 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- American LegalNet, Inc. www.FormsWorkflow.com 2. List your employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Dates of Emplyoment From $ To From $ To From To From $ To $ Employer Address Gross Monthly Pay 3. List your spouse's employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Dates of Emplyoment From $ To From $ To From To From $ To $ Employer Address Gross Monthly Pay -3- American LegalNet, Inc. www.FormsWorkflow.com 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 institutuional 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 sopuse owns. Do not list clothing and ordinary household furnishing. Home Value Other Real Estate Value $ $ Motor Vehicle 1: Make & Year Model Registration # $ Value Motor Vehicle 2: Make & Year Model Registration # $ Value -4- American LegalNet, Inc. www.FormsWorkflow.com Other Assets Value $ $ $ 6. State every person, business, or organization owing you or 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. If a dependent is a minor, list only the initials and not the full name. Name Relationship Age -5- American LegalNet, Inc. www.FormsWorkflow.com 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 rate. You Spouse Rent or home-mortgage payment (include lot rented for mobile home) - Are real estate taxes included? No Yes No Yes - Is property insurance included? 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 payments) Recreation, entertainment, newspapers, magazines, etc. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 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): (name): $ $ $ $ $ $ $ $ $ $ $ $ $ $ - Department Store - Motor Vehicle......................................................................................................................... $ -6- American LegalNet, Inc. www.FormsWorkflow.com Alimony, maintenance, and support paid to others Regular expenses for the 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 attorney's name, address, and telephone number. Name Address City Telephone Number (ex., 4153558000) 11. Have you paid--or will you be paying--anyone other than attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion
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