Affidavit In Support Of Motion To Proceed On Appeal In Forma Pauperis - Indiana Court Of Appeals
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1
2(SAMPLE AFFIDAVIT IN SUPPORT OF
Form #App. R. 40-1
MOTION TO PROCEED ON APPEAL
IN FORMA PAUPERIS)
IN THE
[INDICATE INDIANA COURT OF APPEALS OR GIVE NAME OF TRIAL COURT]
NO. ____________________
______________________________________________________________________________
)
Appeal from the _______ Court
__________________________
)
[Insert name], Appellant,
)
)
Trial Court Case No:
vs.
)
_____________________
)
)
The Honorable ________, Judge
)
)
__________________________
)
[Insert name], Appellee.
)
______________________________________________________________________________
AFFIDAVIT IN SUPPORT OF MOTION TO
PROCEED ON APPEAL IN FORMA PAUPERIS
I, _____________, state, under penalties of perjury, that I am the [Appellant; Appellee] 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:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
[INSERT ISSUES]
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? Yes No
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
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