Form 4 Motion-Financial Affidavit (For All Non-CJA Cases) {4}

UNITED STATES COURT OF APPEALSFOR THE SIXTH CIRCUITv.Case No:MOTION FOR PAUPER STATUSI move to waive the payment of the appellate filing fee under Fed. R. App. P. 24 because I am apauper. This motion is supported by the attached financial affidavit.The issues which I wish to raise on appeal are:Signed: Date: Address: United States Court of Appeals Page 1FORM 4 - AFFIDAVIT ACCOMPANYING MOTION FOR PERMISSION TO APPEAL IN FORMA PAUPERISUpdated: February 2014 American LegalNet, Inc. www.FormsWorkFlow.com FORM 4.AFFIDAVIT ACCOMPANYING MOTION FORPERMISSION TO APPEAL IN FORMA PAUPERISUnited States Court of Appealsfor the Sixth Circuitv.Case No:Affidavit in Support of Motion I swear or affirm under penalty of perjury that,because of my poverty, I cannot prepay thedocket fees of my appeal or post a bond forthem. I believe I am entitled to redress. I swearor affirm under penalty of perjury underUnited States laws that my answers on thisform are true and correct. (28 U.S.C. 247247 1746;18 U.S.C. 247247 1621.)Instructions Complete all questions in this application andthen sign it. Do not leave any blanks: if theanswer to a question is "0," "none," or "notapplicable (N/A)," write that response. If youneed more space to answer a question or toexplain your answer, attach a separate sheet ofpaper identified with your name, your case'sdocket number, and the question number. Signed: Date: My issues on appeal are:]]]]]United States Court of Appeals Page 2FORM 4 AFFIDAVIT ACCOMPANYING MOTION FOR PERMISSION TO APPEAL IN FORMA PAUPERISUpdated: February 2014 American LegalNet, Inc. www.FormsWorkFlow.com 1.For both you and your spouse estimate the average amount of money received from each of thefollowing 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, thatis, amounts before any deductions for taxes or otherwise. Income sourceAverage monthly amount during the past 12 monthsAmount expected next monthYouSpouseYouSpouseEmploymentSelf-employmentIncome from real property (such as rental income)Interest and dividendsGiftsAlimonyChild supportRetirement (such as social security,pensions, annuities, insurance)Disability (such as socialsecurity, insurance payments)Unemployment paymentsPublic-assistance (such as welfare)Other (specify):Total monthly income:2.List your employment history for the past two years, most recent employer first. (Gross monthlypay is before taxes or other deductions.)EmployerAddressDates of EmploymentGrossmonthly payUnited States Court of Appeals Page 3FORM 4 AFFIDAVIT ACCOMPANYING MOTION FOR PERMISSION TO APPEAL IN FORMA PAUPERISUpdated: February 2014 American LegalNet, Inc. www.FormsWorkFlow.com 3.List your spouse's employment history for the past two years, most recent employer first. (Grossmonthly pay is before taxes or other deductions.)EmployerAddressDates of Employment GrossMonthly 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 financialinstitution.Financial InstitutionType of AccountAmount YouHaveAmountYour Spouse HasIf you are a prisoner seeking to appeal a judgment in a civil action or proceeding, you must attacha statement certified by the appropriate institutional officer showing all receipts, expenditures, andbalances 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 eachaccount.5.List the assets, and their values, which you own or your spouse owns. Do not list clothing andordinary household furnishings.Home (Value)Other real estate (Value)Motor Vehicle #1 (Value)Make & year: Model:Registration #:Motor Vehicle #2 (Value)Other assets (Value)Other assets (Value)Make & year: Model: Registration #: United States Court of Appeals Page 4FORM 4 AFFIDAVIT ACCOMPANYING MOTION FOR PERMISSION TO APPEAL IN FORMA PAUPERISUpdated: February 2014 American LegalNet, Inc. www.FormsWorkFlow.com 6.State every person, business, or organization owing you or your spouse money, and the amountowed.Person owing you or your spouse moneyAmount owedto youAmount owedto your spouse7.State the persons who rely on you or your spouse for support.NameRelationshipAgeUnited States Court of Appeals Page 5FORM 4 AFFIDAVIT ACCOMPANYING MOTION FOR PERMISSION TO APPEAL IN FORMA PAUPERISUpdated: February 2014 American LegalNet, Inc. www.FormsWorkFlow.com 8.Estimate the average monthly expenses of you and your family. Show separately the amountspaid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually,or annually to show the monthly rate.YouYourSpouseRent or home-mortgage payment (including lot rented for mobile home)Are real estate taxes included?Yes NoIs property insurance included?Yes NoUtilities (electricity, heating fuel, water, sewer, and telephone)Home maintenance (repairs and upkeep)FoodClothingLaundry and dry-cleaningMedical and dental expensesTransportation (not including motor vehicle expenses)Recreation, entertainment, newspapers, magazines, etc.Insurance (not deduced from wages or included in mortgage payments)Homeowner222s or renter222sLifeHealthMotor vehicleOther:Taxes (not deducted from wages or included in mortgage payments)specify: Installment paymentsMotor VehicleCredit card (name): Department store (name):Other:Alimony, maintenance, and support paid to othersRegular expenses for operation of business, profession, or farm (attachdetail)Other (specify):Total monthly expenses:United States Court of Appeals Page 6FORM 4 AFFIDAVIT ACCOMPANYING MOTION FOR PERMISSION TO APPEAL IN FORMA PAUPERISUpdated: February 2014 American LegalNet, Inc. www.FormsWorkFlow.com 9.Do you expect any major changes to your monthly income or expenses or in your assets orliabilities during the next 12 months?Yes NoIf yes, describe on an attached sheet.10.Have you spent or will you be spending any money for expenses or attorney fees in connectionwith this lawsuit?Yes NoIf yes, how much? $11.Provide any other information that will help explain why you cannot pay the docket fees for yourappeal.12.State the address of your legal residence.Your daytime phone number:()Your age:Your years of schooling:Your social-security number:United States Court of Appeals Page 7FORM 4 AFFIDAVIT ACCOMPANYING MOTION FOR PERMISSION TO APPEAL IN FORMA PAUPERISUpdated: February 2014 American LegalNet, Inc. www.FormsWorkFlow.com