Application To Appeal In Forma Pauperis Form Page 4
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66.
State every person, business, or organization owing you or your spouse money, and the
amount owed.
Person owing you or your spouse
Amount owed to you
Amount owed to your
money
spouse
$
$
$
$
$
$
$
$
7.
State the persons who rely on you or your spouse for support.
Name [or, if a minor (i.e., underage), initials only]
Relationship
Age
8.
Estimate the average monthly expenses of you and your family. Show separately the
amounts paid by your spouse. Adjust any payments that are made weekly, biweekly,
quarterly, semiannually, or annually to show the monthly rate.
You
Your Spouse
Rent or home-mortgage payment (including lot rented for
$
$
mobile home)
Are real estate taxes included?
[ ] Yes [ ] No
Is property insurance included?
[ ] Yes [ ] No
Utilities (electricity, heating fuel, water, sewer, and telephone)
$
$
Home maintenance (repairs and upkeep)
$
$
Food
$
$
Clothing
$
$
Laundry and dry-cleaning
$
$
Medical and dental expenses
$
$
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Parent category: Legal