Application And Request To Proceed In Forma Pauperis On Appeal

UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF NORTH CAROLINA (Plaintiff or Petitioner) v. APPLICATION AND REQUEST TO PROCEED IN FORMA PAUPERIS ON APPEAL (Defendant(s) or Respondent(s)) I, , declare that I am the plaintiff or petitioner in the above-entitled case: that in support of my request 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: I further state 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? a. Yes No 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 last employment and the amount of the salary and wages per month which you received. American LegalNet, Inc. www.FormsWorkFlow.com 2. List anyone who helps support you or shares support in any way and describe the type and amount of support for the last 12 months. [If no one, write "No One."] 3. Have you received within the past twelve months any money from any of the following sources? a. b. c. d. e. Business, profession or form of self-employment? Rent payments, interest or dividends? Pensions, annuities or life insurance payments? Gifts or inheritances? Any other sources? Yes Yes Yes Yes Yes No No No No No If the answer to any of the above is yes, describe each source of money and state the amount received from each during the past twelve months. 4. Do you own any cash, or do you have money in a checking, savings or any other kind of account other than a prison account? Yes No If the answer is yes, describe the account, its location, and total value of each account. 5. Do you own any real estate, stocks, bonds, notes, automobiles or other valuable property (excluding ordinary household furnishings and clothing)? Yes No If the answer is yes, describe the property and state its approximate value. (Separately list all jewelry valued at over $50.00.) 6. List persons who are dependent upon you for support, state your relationship to those persons and indicate how much you actually contributed toward their support for the last 12 months. I declare under the penalty of perjury that all of the foregoing is complete, true and correct. (Date) -2- (Signature of Plaintiff or Petitioner) Clear Form Print Form American LegalNet, Inc. www.FormsWorkFlow.com