[United States District Court]{.smallcaps}

for the

\<\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\> DISTRICT OF
\<\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\>

+------------------------------+---+---------------------+
| \<Name(s) of plaintiff(s)\>, | ) | Case No. \<Number\> |
|                              |   |                     |
| Plaintiff(s)                 | ) |                     |
|                              |   |                     |
| v\.                          | ) |                     |
|                              |   |                     |
| \<Name(s) of defendant(s)\>, | ) |                     |
|                              |   |                     |
| Defendant(s)                 | ) |                     |
|                              |   |                     |
|                              | ) |                     |
|                              |   |                     |
|                              | ) |                     |
|                              |   |                     |
|                              | ) |                     |
|                              |   |                     |
|                              | ) |                     |
|                              |   |                     |
|                              | ) |                     |
+------------------------------+---+---------------------+
|                              |   |                     |
+------------------------------+---+---------------------+

**AFFIDAVIT ACCOMPANYING MOTION**

**FOR PERMISSION TO APPEAL IN FORMA PAUPERIS**

+----------------------------------+----------------------------------+
| **Affidavit in Support of Motion | **Instructions**                 |
| **                               |                                  |
|                                  | Complete all questions in this   |
| I swear or affirm under penalty  | application and then sign it. Do |
| of perjury that, because of my   | not leave any blanks: if the     |
| poverty, I cannot prepay the     | answer to a question is \"0,\"   |
| docket fees of my appeal or post | \"none,\" or \"not applicable    |
| a bond for them. I believe I am  | (N/A),\" write that response. If |
| entitled to redress. I swear or  | you need more space to answer a  |
| affirm under penalty of perjury  | question or to explain your      |
| under United States laws that my | answer, attach a separate sheet  |
| answers on this form are true    | of paper identified with your    |
| and correct. (28 U.S.C. § 1746;  | name, your case\'s docket        |
| 18 U.S.C. § 1621.)               | number, and the question number. |
|                                  |                                  |
| Signed:                          | Date:                            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_       | \_\_\_\_\_\_\_\_\_\_\_\_\_       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+----------------------------------+----------------------------------+
|                                  |                                  |
+----------------------------------+----------------------------------+

My issues on appeal are:

1\. *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 during the past 12 months**   **Amount expected next month**            
                                                                                                                                                                          
                                                                         You                                                    Spouse                           You      Spouse
                                                                                                                                                                          
  Employment                                                             \$                                                     \$                               \$       \$
  Self-employment                                                        \$                                                     \$                               \$       \$
                                                                                                                                                                          
  Income from real property (such as rental income)                      \$                                                     \$                               \$       \$
                                                                                                                                                                          
  Interest and dividends                                                 \$                                                     \$                               \$       \$
  Gifts                                                                  \$                                                     \$                               \$       \$
  Alimony                                                                \$                                                     \$                               \$       \$
  Child support                                                          \$                                                     \$                               \$       \$
  Retirement (such as social security, pensions, annuities, insurance)   \$                                                     \$                               \$       \$
  Disability (such as social security, insurance payments)               \$                                                     \$                               \$       \$
  Unemployment payments                                                  \$                                                     \$                               \$       \$
  Public-assistance (such as welfare)                                    \$                                                     \$                               \$       \$
  Other (specify):                                                       \$                                                     \$                               \$       \$
                                                                                                                                                                          
  ** Total monthly income:**                                             **\$**                                                 **\$**                           **\$**   **\$**
                                                                                                                                                                          
  ---------------------------------------------------------------------- ------------------------------------------------------ -------------------------------- -------- --------

2\. *List your employment history for the past two years, most recent
employer first. (Gross monthly pay is before taxes or other
deductions.)*

  -------------- ------------- ------------------------- -----------------------
  **Employer**   **Address**   **Dates of employment**   **Gross monthly pay**
                                                         \$
                                                         \$
                                                         
                                                         \$
                                                         
  -------------- ------------- ------------------------- -----------------------

3\. *List your spouse\'s employment history for the past two years, most
recent employer first. (Gross monthly pay is before taxes or other
deductions.)*

  -------------- ------------- ------------------------- -----------------------
  **Employer**   **Address**   **Dates of employment**   **Gross monthly pay**
                                                         \$
                                                         \$
                                                         
                                                         \$
                                                         
  -------------- ------------- ------------------------- -----------------------

4\. *How much cash do you and your spouse have? \$\_\_\_\_\_\_\_\_*

*Below, state any money you or your spouse have in bank accounts or in
any other financial institution.*

  --------------------------- --------------------- --------------------- ----------------------------
  **Financial Institution**   **Type of Account**   **Amount you have**   **Amount your spouse has**
                                                    \$                    \$
                                                    \$                    \$
                                                                          
                                                    \$                    \$
                                                                          
  --------------------------- --------------------- --------------------- ----------------------------

***If you are a prisoner, you must attach a statement certified by the
appropriate institutional officer showing all receipts, expenditures,
and balances during the last six months in your institutional accounts.
If you have multiple accounts, perhaps because you have been in multiple
institutions, attach one certified statement of each account.***

5\. *List the assets, and their values, which you own or your spouse
owns. Do not list clothing and ordinary household furnishings.*

  ---------------------- ----------------------- ----------------------
  **Home**               **Other real estate**   **Motor vehicle #1**
  (Value) \$             (Value) \$              (Value) \$
                                                 
                                                 Make and year:
                                                 
                                                 Model:
                                                 
                                                 Registration #:
                                                 
  **Motor vehicle #2**   **Other assets**        **Other assets**
  (Value) \$             (Value) \$              (Value) \$
  Make and year:                                 
  Model:                                         
                                                 
  Registration #:                                
                                                 
  ---------------------- ----------------------- ----------------------

6\. *State every person, business, or organization owing you or your
spouse money, and the amount owed.*

  ------------------------------------------- ------------------------ --------------------------------
  **Person owing you or your spouse money**   **Amount owed to you**   **Amount owed to your 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           |                    |                 |    |
+--------------------+--------------------+-----------------+----+
| Transportation     | \$                 | \$              |    |
| (not including     |                    |                 |    |
| motor vehicle      |                    |                 |    |
| payments)          |                    |                 |    |
+--------------------+--------------------+-----------------+----+
| Recreation,        | \$                 | \$              |    |
| entertainment,     |                    |                 |    |
| newspapers,        |                    |                 |    |
| magazines, etc.    |                    |                 |    |
+--------------------+--------------------+-----------------+----+
|                    |                    |                 |    |
+--------------------+--------------------+-----------------+----+
| Insurance (not     |                    |                 |    |
| deducted from      |                    |                 |    |
| wages or included  |                    |                 |    |
| in mortgage        |                    |                 |    |
| payments)          |                    |                 |    |
+--------------------+--------------------+-----------------+----+
|                    |                    |                 |    |
+--------------------+--------------------+-----------------+----+
|                    | Homeowner\'s or    | \$              | \$ |
|                    | renter\'s:         |                 |    |
+--------------------+--------------------+-----------------+----+
|                    |                    |                 |    |
+--------------------+--------------------+-----------------+----+
|                    | Life:              | \$              | \$ |
+--------------------+--------------------+-----------------+----+
|                    | Health:            | \$              | \$ |
+--------------------+--------------------+-----------------+----+
|                    | Motor vehicle:     | \$              | \$ |
+--------------------+--------------------+-----------------+----+
|                    | Other:             | \$              | \$ |
+--------------------+--------------------+-----------------+----+
|                    |                    |                 |    |
+--------------------+--------------------+-----------------+----+
| Taxes (not         | \$                 | \$              |    |
| deducted from      |                    |                 |    |
| wages or included  |                    |                 |    |
| in mortgage        |                    |                 |    |
| payments)          |                    |                 |    |
| (specify):         |                    |                 |    |
+--------------------+--------------------+-----------------+----+
|                    |                    |                 |    |
+--------------------+--------------------+-----------------+----+
| Installment        |                    |                 |    |
| payments           |                    |                 |    |
+--------------------+--------------------+-----------------+----+
|                    |                    |                 |    |
+--------------------+--------------------+-----------------+----+
|                    | Motor Vehicle:     | \$              | \$ |
+--------------------+--------------------+-----------------+----+
|                    |                    |                 |    |
+--------------------+--------------------+-----------------+----+
|                    | Credit card        | \$              | \$ |
|                    | (name):            |                 |    |
+--------------------+--------------------+-----------------+----+
|                    | Department store   | \$              | \$ |
|                    | (name):            |                 |    |
+--------------------+--------------------+-----------------+----+
|                    | Other:             | \$              | \$ |
+--------------------+--------------------+-----------------+----+
|                    |                    |                 |    |
+--------------------+--------------------+-----------------+----+
| Alimony,           | \$                 | \$              |    |
| maintenance, and   |                    |                 |    |
| support paid to    |                    |                 |    |
| others             |                    |                 |    |
+--------------------+--------------------+-----------------+----+
| Regular expenses   | \$                 | \$              |    |
| for operation of   |                    |                 |    |
| business,          |                    |                 |    |
| profession, or     |                    |                 |    |
| farm (attach       |                    |                 |    |
| detailed           |                    |                 |    |
| statement)         |                    |                 |    |
+--------------------+--------------------+-----------------+----+
| Other (specify):   | \$                 | \$              |    |
+--------------------+--------------------+-----------------+----+
|                    |                    |                 |    |
+--------------------+--------------------+-----------------+----+
| ** Total monthly   | **\$**             | **\$**          |    |
| expenses:**        |                    |                 |    |
+--------------------+--------------------+-----------------+----+
|                    |                    |                 |    |
+--------------------+--------------------+-----------------+----+

9\. *Do you expect any major changes to your monthly income or expenses
or in your assets or liabilities during the next 12 months?*

\[ \] Yes \[ \] No If yes, describe on an attached sheet.

10\. *Have you paid --- or will you be paying --- an attorney any money
for services in connection with this case, including the completion of
this form?* \[ \] Yes \[ \] No

*If yes, how much?* \$ \_\_\_\_\_\_\_\_\_\_\_\_

*If yes, state the attorney\'s name, address, and telephone number:*

11\. *Have you paid-or will you be paying-anyone other than an attorney
(such as a paralegal or a typist) any money for services in connection
with this case, including the completion of this form?* \[ \] Yes \[ \]
No

*If yes, how much?* \$ \_\_\_\_\_\_\_\_\_\_\_\_

*If yes, state the person\'s name, address, and telephone number:*

12\. *Provide any other information that will help explain why you
cannot pay the docket fees for your appeal.*

13\. *State the \[city and state\] of your legal residence.*

*Your daytime phone number*:* *(\_\_\_\_) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Your age*: \_\_\_\_\_\_\_\_ *Your years of schooling*: \_\_\_\_\_\_\_\_

*\[Last four digits of\] your social-security number*: \_\_\_\_\_\_\_