Application To Appeal In Forma Pauperis Form

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Application to Appeal In Forma Pauperis
______________________v. ______________________
Appeal No. __________________
District Court or Agency No. _________________
Affidavit in Support of Motion
I swear or affirm under penalty of perjury that,
Complete all questions in this application and then
because of my poverty, I cannot prepay the docket
sign it. Do not leave any blanks: if the answer to a
fees of my appeal or post a bond for them. I believe
question is "0," "none," or "not applicable (N/A),"
I am entitled to redress. I swear or affirm under
write that response. If you need more space to answer
penalty of perjury under United States laws that my
a question or to explain your answer, attach a separate
answers on this form are true and correct. (28
sheet of paper identified with your name, your case's
U.S.C. § 1746; 18 U.S.C. § 1621.)
docket number, and the question number.
Signed: _____________________________
Date: _____________________________
My issues on appeal are: (required):
For both you and your spouse estimate the average amount of money received from each
of the following sources during the past 12 months. Adjust any amount that was received
weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use
gross amounts, that is, amounts before any deductions for taxes or otherwise.
Income source
Average monthly
Amount expected next
amount during the past
12 months
Income from real property (such as
rental income)
- 1 -
12/01/2013 SCC


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