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Form Appellate 40 2

This document is an affidavit in support of a motion to proceed on appeal in forma pauperis. It begins with identifying information about the court and case. It then states that the appellant, due to poverty, is unable to pay court fees or costs for the appeal or provide security. The appellant believes they are entitled to redress. It lists the issues to be presented on appeal. The appellant then swears that their responses to questions about their ability to pay are true. The questions ask about current employment and income, assets, dependents, and understanding of penalties for perjury. The appellant signs and dates the document.

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428 views2 pages

Form Appellate 40 2

This document is an affidavit in support of a motion to proceed on appeal in forma pauperis. It begins with identifying information about the court and case. It then states that the appellant, due to poverty, is unable to pay court fees or costs for the appeal or provide security. The appellant believes they are entitled to redress. It lists the issues to be presented on appeal. The appellant then swears that their responses to questions about their ability to pay are true. The questions ask about current employment and income, assets, dependents, and understanding of penalties for perjury. The appellant signs and dates the document.

Uploaded by

Risha rey
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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(SAMPLE AFFIDAVIT IN SUPPORT OF Form #App. R.

40-2
MOTION TO PROCEED ON APPEAL
IN FORMA PAUPERIS)

IN THE
[INDICATE INDIANA COURT OF APPEALS OR SUPREME COURT OR GIVE NAME
OF TRIAL COURT]

NO. ____________________
______________________________________________________________________________

) Appeal from the _______ [Trial Court or


__________________________ ) Administrative Agency]
[Insert name], Appellant, )
) Trial or Administrative Agency Case No:
vs. ) _____________________
)
) The Honorable ________, Judge
)
)
__________________________ )
[Insert name], Appellee. )
______________________________________________________________________________

AFFIDAVIT IN SUPPORT OF MOTION TO


PROCEED ON APPEAL IN FORMA PAUPERIS

I, _____________, state, under penalties of perjury, that I am the [Appellant; Appellee]


in the above-entitled case; that in support of my motion to proceed on appeal without being
required to prepay fees, costs or give security therefor, I state that because of my poverty I am
unable to pay the costs of said proceeding or to give security therefor; that I believe I am entitled
to redress; and that the issues which I desire to present on appeal are the following:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
[INSERT ISSUES]

I further swear that the responses which I have made to the questions and instructions
below relating to my ability to pay the cost of prosecuting the appeal are true.

1. Are you presently employed? Yes  No

a. If the answer is yes, state the amount of your salary or wages per month and give
the name and address of your employer.
b. If the answer is no, state the date of your last employment and the amount of the
salary and wages per month which you received.

2. Have you received within the past twelve months any income from a business, profession
or other form of self-employment, or in the form of rent payments, interest, dividends,
retirement or disability payments, government benefits or other source? Yes  No

a. If the answer is yes, describe each source of income, and state the amount
received from each during the past twelve months.

3. Do you own any cash or checking or savings account? Yes  No

a. If the answer is yes, state the total value of the items owned.

4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property
(excluding ordinary household furnishings and clothing)?

a. If the answer is yes, describe the property and state its approximate value.

5. List the persons who are dependent upon you for support and state your relationship to
those persons.

I understand that a false statement or answer to any questions in this affidavit will subject
me to penalties for perjury.

__________________________________________
Signature

__________________________________________
Date

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