Affidavit For Proceeding In Forma Pauperis Page 3
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1
2
3CONFIDENTIAL
15.
I am presently $____________ in debt, excluding car loans and real estate
mortgage/loans.
16.
Other factors which support your request are (explain unusual medical expenses, emergencies,
reasons that the family money is not available to you, or other circumstances to help the Judge
understand your situation):
By signing this Affidavit, I am certifying that these statements are true under penalty of
perjury. I understand that if I provide false information on the form it may lead to criminal
charges. I understand that failure to execute the form or failure to provide information or
requested records may result in denial of my motion to proceed In Forma Pauperis. I am
authorizing that the facts contained in this Affidavit may be verified by any means
required.
Dated:
Signature
(Sign only in front of notary public or court administrator)
Sworn/affirmed before me this
Name:
day of
,
.
Address:
City/State/Zip:
Notary Public \ Deputy Court Administrator
Telephone: (
)
IFP102
State
ENG
Rev 02/13
ww.mncourts.gov/forms
Page 3 of 3
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