IFP Motion (PLRA Language) {A-14}

UNITED STATES COURT OF APPEALS FOR THE TENTH CIRCUIT Case No. __________________ Plaintiff/Petitioner - Appellant, v. Motion for Leave to Proceed on Appeal Without Prepayment of Costs or Fees (non-PLRA) Defendant/Respondent Appellee. I, _________________________________________, the petitioner/appellant in the captioned case move this court for leave to proceed in forma pauperis. In support of this motion, I state that because of my poverty, I am unable to pay the costs of said proceedings or give security therefor, I submit the following financial declaration. American LegalNet, Inc. www.FormsWorkFlow.com FINANCIAL DECLARATION Affidavit to Accompany Motion for Permission to Appeal in Forma Pauperis I swear or affirm under penalty of perjury that because of my poverty I am unable to pay the docket fees of my appeal or to post a bond for them. I believe I am entitled to a different result than that reached in the district court. I further swear or affirm under penalty of perjury that the responses which I have made to the questions and instructions below relating to my ability to pay the fees for my appeal are true. Instructions. Please complete all questions in this application and then sign it on the last page. If the answer to any question is "0" or "none," or the question is "not applicable", so indicate by writing "0", "none", or "not applicable (N/A)". If additional space is needed to answer any question or to explain your answer to any question, please use and attach a separate sheet of paper identified with your name, the docket number of your case and the number of the question. My issues on appeal are: 1. Are you or your spouse currently employed? Yes _____ No _____ 2. If you or your spouse are currently employed, state the name and address of your employer, the length of your employment with that employer, and your monthly gross pay. Gross pay is pay before any taxes or other deductions are taken. If you have more than one employer, please provide the information requested below about the other employer(s) on a separate sheet of paper and attach it to this application. Yourself: Your Spouse: A-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Name and Address of Employer _________________________________ _________________________________ _________________________________ Length of Employment _____ ______ Years Months Monthly Gross Pay $____________ Name and Address of Employer _________________________________ _________________________________ _________________________________ Length of Employment _____ ______ Years Months Monthly Gross Pay $____________ 3. If you are currently unemployed, state the date of your last employment and your monthly gross pay during your last month of employment. Gross pay is pay before any taxes or other deductions are taken. Date of last employment (Month/Year) for yourself _______________; spouse _____________ Monthly gross pay during last month of employment $____________ 4. State whether you or your spouse have received money from any of the following sources during the past twelve months, and, if so, the average monthly amount from that source. Adjust any money that was received weekly, bi-weekly, quarterly, semi-annually, or annually to show the monthly rate. Amount expected next Did you receive money from Average monthly amount during month past 12 months for you and your any of the following sources during the past 12 months? spouse if applicable. Spouse You Spouse You Self-employment Y/N ___ $ _______ $ _______ $ _______ $ _______ Income from real property (such as rental income) Interest and dividends Gifts Alimony Y/N ___ Y/N ___ Y/N ___ Y/N ___ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ A-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13 Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Child Support Retirement income from sources such as social security, private pensions, annuities, or insurance policies Y/N ___ $ _______ $ _______ $ _______ $ _______ Y/N ___ Disability payments such as social security, other state or federal government, or insurance payments Unemployment payments Public assistance payments such as welfare payments Other sources of money (specify: ____________________) TOTAL $ _______ $ _______ $ _______ $ _______ Y/N ___ Y/N ___ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ Y/N ___ Y/N ___ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ 5. State the amount of cash you and your spouse have: $ ___________ State below any money you or your spouse have in savings, checking, or other accounts in a bank or other financial institution. Bank or Other Financial Institution: Type of Account such as savings, checking, or CD: ________________ ________________ ________________ Amount you have: $ _________ $ _________ $ _________ Amount your spouse has: $ _________ $ _________ $ _________ __________________________________ __________________________________ __________________________________ If you are a prisoner seeking to appeal a judgment in a civil action or proceeding, 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. A-14 Motion for Leave to Proceed on Appeal without Prepayment of Costs or Fees (Non-PLRA) 12/13 Page 4 American LegalNet, Inc. www.FormsWorkFlow.com 6. State below the assets owned by you and your spouse. Do not list ordinary household furnishings and clothing. Home Address: _________________________________ _________________________________ Address: _________________________________ _________________________________ Model/Year: ________________________ Model/Year: ________________________ Description: ______________________ _________________________________ Value: $ _________ Amount owed on mortgages and liens: $ _________ Value: $ _________ Amount owed on mortgages and liens: $ _________ Value: $ _________ Amount owed: $ _________ Value: $ _________ Amount owed: $ _________ Value: