From the 'Lectric Law Library
Affidavit to Accompany Motion for
Leave to Appeal In Forma Pauperis Form

                   UNITED STATES DISTRICT COURT 
                   FOR THE XXXX DISTRICT OF XXXX


 United States of America   |
 v.                         |          NO. XX
 A. B.                      |
____________________________|

AFFIDAVIT IN SUPPORT OF MOTION TO PROCEED ON APPEAL IN FORMA PAUPERIS

  I, XXXXXXXXXXXX being first duly sworn, depose and say that I am the
XXXXX, in the above-entitled case; that in support of my motion to proceed
on appeal without being required to prepay fees, costs or give security
therefor, I state that because of my poverty I am unable to pay the costs
of said proceeding or to give security therefor; that I believe I am
entitled to redress; and that the issues which I desire to present on
appeal are the following:


  I further swear that the responses which I have made to the questions and
instructions below relating to my ability to pay the 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 income from a
business, profession or other form of self-employment, or in the form of
rent payments, interest, dividends, or other source?
    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.

4. 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 its
approximate value.

5. List the persons who are dependent upon you for support and state 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.

XXXXXXXXXXXX

  SUBSCRIBED AND SWORN TO before me this XXXX day of XXXXXX, 19X.

  Let the applicant proceed without prepayment of costs or fees or the
necessity of giving security therefor.
             XXXXXXXXXXXX,
            District Judge.

from FED RULES OF APPELLATE PROCEDURE APPENDIX OF FORMS

Need a Lawyer? Check Out The 'Lectric Law Library's Searchable Attorney Directory
& our Searchable Expert Witness Directory

Search by
	Web Search Search the Library

* IMPORTANT CAUTION *
Most of our Forms are ONLY General, Generic Examples of possible formats & contents.   Legal Requirements & Accepted Customs Can and Do vary Greatly between (and even within) States and can Change Often.   To Not Create More Problems than they Solve Most MUST be Properly Drafted and Modified to Fit Specific Venues and Circumstances!
* * * * * * * * * * * * *
For Up-To-Date Forms Covering Just About Every State & Situation plus Summaries of
Relevant Laws We STRONGLY SUGGEST Checking Out

(This should open a new window. Close it when you're done and you'll be back here.)

We've lots of related material, so wander around & explore places like our
State Courts & Civil Law Topic Areas and Legal Professional's Lounge

Our Main Forms Room
Business & General Forms
* * * * * * * * * *
The Library Rotunda
Our Central Hub, Directory and Index
The Reference Room
Dozens of Topic Areas & Our Law Lexicon

[Last Revised 3/02]