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Affidavit In Support Of Motion To Proceed On Appeal In Forma Pauperis - Indiana Court Of Appeals Page 2

salary and wages per month which you received.

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,

retirement or disability payments, government benefits or other source? Yes  No

If the answer is yes, describe each source of income, and state the amount received

from each during the past twelve months.

Do you own any cash or checking or savings account? Yes  No

If the answer is yes, state the total value of the items owned.

Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property

(excluding ordinary household furnishings and clothing)?

If the answer is yes, describe the property and state its approximate value.

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.

__________________________________________

Signature

__________________________________________

Date

Affidavit In Support Of Motion To Proceed On Appeal In Forma Pauperis - Indiana Court Of Appeals Page 2