UNITED STATES DISTRICT COURT

for the

__________________ DISTRICT OF__________________ 

________________________________,

 

 Plaintiff(s)

 v. 

________________________________, 

 Defendant(s)

)

) 

) 

) 

) 

) 

) 

) 

) 

)

Case No. _____________ 

AFFIDAVIT ACCOMPANYING MOTION

FOR PERMISSION TO APPEAL IN FORMA PAUPERIS

Affidavit in Support of Motion 

 I swear or affirm under penalty of perjury 

that, because of my poverty, I cannot prepay 

the docket fees of my appeal or post a bond for 

them. I believe I am entitled to redress. I swear 

or affirm under penalty of perjury under United 

States laws that my answers on this form are 

true and correct. (28 U.S.C. § 1746; 18 U.S.C. 

§ 1621.) 

 Signed: _____________________________ 

Instructions

 Complete all questions in this application and 

then sign it. Do not leave any blanks: if the 

answer to a question is "0," "none," or "not 

applicable (N/A)," write in that response. If 

you need more space to answer a question or to 

explain your answer, attach a separate sheet of 

paper identified with your name, your case's 

docket number, and the question number. 

 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. 

Case 4:22-cv-00262-P Document 12-1 Filed 04/18/22 Page 1 of 6 PageID 137
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

$ 

$ 

$ 

Case 4:22-cv-00262-P Document 12-1 Filed 04/18/22 Page 2 of 6 PageID 138
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 seeking to appeal a judgment in a civil action or proceeding, 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 #: 

Case 4:22-cv-00262-P Document 12-1 Filed 04/18/22 Page 3 of 6 PageID 139
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 under 18, 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 (include 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) $ $ 

Case 4:22-cv-00262-P Document 12-1 Filed 04/18/22 Page 4 of 6 PageID 140
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.

Case 4:22-cv-00262-P Document 12-1 Filed 04/18/22 Page 5 of 6 PageID 141
10. Have you spent — or will you be spending — any money for expenses or attorney fees in 

connection with this lawsuit? [ ] Yes [ ] No

If yes, how much? $ ____________ 

11. Provide any other information that will help explain why you cannot pay the docket fees 

for your appeal. 

12. 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: _______

Case 4:22-cv-00262-P Document 12-1 Filed 04/18/22 Page 6 of 6 PageID 142