Motion And Affidavit For Leave To Proceed On Appeal Pursuant To 28 USC Section 1915 And Fed. R. App. P. 24

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLORADO Civil Action No. , Plaintiff(s)/Petitioner(s), v. , Defendant(s)/Respondents. MOTION AND AFFIDAVIT FOR LEAVE TO PROCEED ON APPEAL PURSUANT TO 28 U.S.C. § 1915 AND FED. R. APP. P. 24 I request leave to commence this appeal without prepayment of fees or security therefor pursuant to 28 U.S.C. § 1915 and Fed. R. App. P. 24. I also request that the United States pay for a transcript of the record of proceedings, if any, for inclusion in the record on appeal. In support of my requests, I submit the accompanying affidavit and declare that: (1) (2) I am unable to pay such fees or give security therefor. The issues I desire to raise on appeal are: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (3) (4) (5) I am entitled to redress. I take this appeal in good faith. The appeal is not frivolous and presents a substantial question. I 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. MARITAL STATUS AND DEPENDENTS Rev. 1/12 American LegalNet, Inc. www.FormsWorkFlow.com Single ____ Married ____ Separated ____ Divorced ____ The following individuals are my dependents (Identify minor children by their initials only. Do not include their date of birth.): Name Age Relationship Name Age Relationship Name Age Relationship Name Age Relationship RESIDENCE Street Address: City: Zip Code: State: Telephone: EDUCATION What is the highest level of formal education you have received: __________________________ I can speak, read, write, and understand the English language: Yes _____ No _____ EMPLOYMENT If employed at present, complete the following: Name of employer: Address of employer: Telephone number of employer: How long have you been employed by present employer: Income: Monthly $ If self-employed, state your net income: Monthly $ What is the nature of your self-employment? If unemployed at present, complete the following: I have been unemployed since: Name of last employer: Address of last employer: Telephone number of last employer: Salary or hourly wage received from last employer: $ If spouse is employed, complete the following: Name of employer: How long has spouse been employed by present employer: Income: Monthly $ Weekly $ If receiving public assistance (e.g., welfare, unemployment benefits), complete the following: I have been receiving public assistance since: Monthly benefits: $ Weekly benefits: $ Weekly $ Weekly $ Rev. 1/12 2 American LegalNet, Inc. www.FormsWorkFlow.com REAL AND PERSONAL PROPERTY Real property: Do you own real property? Yes _____ No ______ If yes, describe: Address: Name(s) on title: Estimated value: $ Amount owed: $ Annual income from real property: $ Personal property: Automobile: Make: Name(s) on registration: Estimated value: $ Model: Amount owed: $ Year: Cash on hand: Total amount of cash in banks and savings and loan associations: $ Names and addresses of banks and associations: Other information pertinent to financial status: (Include stocks, bonds, savings bonds, interests in trusts either owned or jointly owned): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Payments for legal assistance: I have paid or will be paying an attorney, or someone other than an attorney (such as a paralegal or typist), money for services in connection with this case, including the No completion of this form. Yes If yes, how much? $ If yes, state the name, address, and telephone number of the attorney or person: FINANCIAL OBLIGATIONS: Rent on house or apartment: Mortgage on house: Gas bill: Electric bill: Telephone bill: Food: Clothing: Automobile loan: Automobile insurance: Other insurance: Payments to retail merchants: Rev. 1/12 MONTHLY PAYMENT: $ $ $ $ $ $ $ $ $ $ $ 3 American LegalNet, Inc. www.FormsWorkFlow.com Total owed: Payments on any other outstanding loans or debts: Total owed: Payments to doctors, hospitals, lawyers: Total owed: Maintenance under separation or dissolution agreement: Child support: Other Payments: Describe: Describe: Describe: Describe: Total monthly payments: $ $ $ $ $ $ $ $ $ Signature Name Street Address City Telephone Number Date: Signature of Affiant State Zip Code SUBSCRIBED AND SWORN TO BEFORE ME THIS ____ day of _____________________, 20____ Notary Public Address My commission expires:_________________________ Rev. 1/12 4 www.FormsWorkflow.com