No.
IN THE
SUPREME COURT OF THE UNITED STATES
— PETITIONER
(Your Name)
VS.
— RESPONDENT(S)
MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS
The petitioner asks leave to file the attached petition for a writ of certiorari
without prepayment of costs and to proceed in forma pauperis.
Please check the appropriate boxes:
䡺 Petitioner has previously been granted leave to proceed in forma pauperis in
the following court(s):
䡺 Petitioner has not previously been granted leave to proceed in forma
pauperis in any other court.
䡺 Petitioner’s affidavit or declaration in support of this motion is attached hereto.
䡺 Petitioner’s affidavit or declaration is not attached because the court below
appointed counsel in the current proceeding, and:
䡺 The appointment was made under the following provision of law:
, or
䡺 a copy of the order of appointment is appended.
(Signature)
AFFIDAVIT OR DECLARATION
IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS
I, , am the petitioner in the above-entitled case. In support of
my motion to proceed in forma pauperis, I state that because of my poverty I am unable to pay
the costs of this case or to give security therefor; and I believe I am entitled to redress.
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 Amount expected
the past 12 months 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 first. (Gross monthly pay
is before taxes or other deductions.)
Employer Address Dates of Gross monthly pay
Employment
$
$
$
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 Gross monthly pay
Employment
$
$
$
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.
Type of account (e.g., checking or savings) Amount you have Amount your spouse has
$ $
$ $
$ $
5. List the assets, and their values, which you own or your spouse owns. Do not list clothing
and ordinary household furnishings.
䡺 Home 䡺 Other real estate
Value Value
䡺 Motor Vehicle #1 䡺 Motor Vehicle #2
Year, make & model Year, make & model
Value Value
䡺 Other assets
Description
Value
6. State every person, business, or organization owing you or your spouse money, and the
amount owed.
Person owing you or Amount owed to you Amount owed to your spouse
your spouse money
$ $
$ $
$ $
7. State the persons who rely on you or your spouse for support. For minor children, list initials
instead of names (e.g. “J.S.” instead of “John Smith”).
Name 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, 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? 䡺 Yes 䡺 No
Is property insurance included? 䡺 Yes 䡺 No
Utilities (electricity, heating fuel,
water, sewer, and telephone) $ $
Home maintenance (repairs and upkeep) $ $
Food $ $
Clothing $ $
Laundry and dry-cleaning $ $
Medical and dental expenses $ $
You Your spouse
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(s) $ $
Department store(s) $ $
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?
䡺 Yes 䡺 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? 䡺 Yes 䡺 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?
䡺 Yes 䡺 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 costs of this case.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on: , 20
(Signature)
No.
IN THE
SUPREME COURT OF THE UNITED STATES
— PETITIONER
(Your Name)
vs.
— RESPONDENT(S)
ON PETITION FOR A WRIT OF CERTIORARI TO
(NAME OF COURT THAT LAST RULED ON MERITS OF YOUR CASE)
PETITION FOR WRIT OF CERTIORARI
(Your Name)
(Address)
(City, State, Zip Code)
(Phone Number)
QUESTION(S) PRESENTED
LIST OF PARTIES
[ ] All parties appear in the caption of the case on the cover page.
[ ] All parties do not appear in the caption of the case on the cover page. A list of
all parties to the proceeding in the court whose judgment is the subject of this
petition is as follows:
RELATED CASES
TABLE OF CONTENTS
OPINIONS BELOW ........................................................................................................ 1
JURISDICTION...................................................................................................................
CONSTITUTIONAL AND STATUTORY PROVISIONS INVOLVED .................................
STATEMENT OF THE CASE ............................................................................................
REASONS FOR GRANTING THE WRIT ..........................................................................
CONCLUSION....................................................................................................................
INDEX TO APPENDICES
APPENDIX A
APPENDIX B
APPENDIX C
APPENDIX D
APPENDIX E
APPENDIX F
TABLE OF AUTHORITIES CITED
CASES PAGE NUMBER
STATUTES AND RULES
OTHER
IN THE
SUPREME COURT OF THE UNITED STATES
PETITION FOR WRIT OF CERTIORARI
Petitioner respectfully prays that a writ of certiorari issue to review the judgment below.
OPINIONS BELOW
[ ] For cases from federal courts:
The opinion of the United States court of appeals appears at Appendix to
the petition and is
[ ] reported at ; or,
[ ] has been designated for publication but is not yet reported; or,
[ ] is unpublished.
The opinion of the United States district court appears at Appendix to
the petition and is
[ ] reported at ; or,
[ ] has been designated for publication but is not yet reported; or,
[ ] is unpublished.
[ ] For cases from state courts:
The opinion of the highest state court to review the merits appears at
Appendix to the petition and is
[ ] reported at ; or,
[ ] has been designated for publication but is not yet reported; or,
[ ] is unpublished.
The opinion of the court
appears at Appendix to the petition and is
[ ] reported at ; or,
[ ] has been designated for publication but is not yet reported; or,
[ ] is unpublished.
1.
JURISDICTION
[ ] For cases from federal courts:
The date on which the United States Court of Appeals decided my case
was .
[ ] No petition for rehearing was timely filed in my case.
[ ] A timely petition for rehearing was denied by the United States Court of
Appeals on the following date: , and a copy of the
order denying rehearing appears at Appendix .
[ ] An extension of time to file the petition for a writ of certiorari was granted
to and including (date) on (date)
in Application No. A .
The jurisdiction of this Court is invoked under 28 U. S. C. § 1254(1).
[ ] For cases from state courts:
The date on which the highest state court decided my case was .
A copy of that decision appears at Appendix .
[ ] A timely petition for rehearing was thereafter denied on the following date:
, and a copy of the order denying rehearing
appears at Appendix .
[ ] An extension of time to file the petition for a writ of certiorari was granted
to and including (date) on (date) in
Application No. A .
The jurisdiction of this Court is invoked under 28 U. S. C. § 1257(a).
CONSTITUTIONAL AND STATUTORY PROVISIONS INVOLVED
STATEMENT OF THE CASE
REASONS FOR GRANTING THE PETITION
CONCLUSION
The petition for a writ of certiorari should be granted.
Respectfully submitted,
Date:
No.
IN THE
SUPREME COURT OF THE UNITED STATES
— PETITIONER
(Your Name)
VS.
— RESPONDENT(S)
PROOF OF SERVICE
I, , do swear or declare that on this date,
, 20 , as required by Supreme Court Rule 29 I have
served the enclosed MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS
and PETITION FOR A WRIT OF CERTIORARI on each party to the above proceeding
or that party’s counsel, and on every other person required to be served, by depositing
an envelope containing the above documents in the United States mail properly addressed
to each of them and with first-class postage prepaid, or by delivery to a third-party
commercial carrier for delivery within 3 calendar days.
The names and addresses of those served are as follows:
I declare under penalty of perjury that the foregoing is true and correct.
Executed on , 20
(Signature)
