Form Ifp102 - Affidavit For Proceeding In Forma Pauperis
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1
2CONFIDENTIAL
State of Minnesota
District Court
County
Judicial District:
Court File Number:
Select County
Case Type:
Plaintiff/Petitioner
Affidavit for Proceeding
vs / and
In Forma Pauperis
(Minn. Stat. § 563.01)
Defendant/Respondent
1.
I am a party in this action. I am a natural person (not a corporation, partnership or other entity).
In good faith, I request a court order waiving court fees and costs. I cannot support my family
and myself and also pay or give security for costs.
2.
I believe that I have valid reasons for pursuing this action. My pleadings (the Petition,
Complaint, Answer, Appeal or other pleading) are attached.
3. a.
I am receiving public assistance under one or more of the following means-tested programs:
MSA (Minnesota Supplemental Assistance Programs);
MFIP (Minnesota Family Investment Program);
Food Stamps;
General Assistance or Discretionary Work Program;
MinnesotaCare, Medical Assistance, or General Assistance Medical Assistance;
Energy Assistance;
b.
I am receiving public assistance under some other means-tested program: (Name the program)
I have attached proof that I receive public assistance (such as MFIP card or cancelled check
from agency) or I will provide proof if requested.
c.
I receive Supplemental Security Income (SSI) as a resource for meeting my expenses.
If you checked #3a or 3c and receive help under one of the listed programs, skip to the signature line
on page 2. If you checked #3b and receive some "Other" means-tested assistance, go to Question 4.
4.
I am represented by attorney
on behalf of
a civil legal services program or volunteer attorney
program, based on indigency. If you checked #4, skip to the signature line on page 2.
5.
My family size is ___________. (Include yourself, your spouse, your minor children, and other
dependents in your household.) For my family size, I counted myself and (list all others):
Name
Age
Relationship to you
6.
My gross annual family income (before taxes and deductions) is $
which is less
than 125% of the Federal Poverty Line for my family size of _________ members. I have
attached proof of my family income or I will provide proof if requested. If you checked #6,
skip to the signature line on page 2.
IFP102
State
ENG
Rev 8/11
Page 1 of 2
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