Affidavit For Proceeding In Forma Pauperis

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State of Minnesota
District Court
Judicial District:
Select County
Court File Number:
Case Type:
Affidavit for Proceeding
In Forma Pauperis
vs / and
(Minn. Stat. § 563.01)
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.
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
 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
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.
4.  I am represented by attorney
on behalf of
a civil legal services
program or volunteer attorney program, based on indigency.
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
Relationship to you
Rev 02/13
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