TBD | Item 21D (FL Bar's Pro Se Handbook)

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.

☐ Petitioner has previously been granted leave to proceed in forma pauperis in the following court(s): ________________________________________________________________

________________________________________________________________

☐ Petitioner has not previously been granted leave to proceed in forma pauperis in any other court.

Petitioner’s affidavit or declaration in support of this motion is attached hereto.

(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 the past 12 months		Amount expected 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 Employment	Gross Monthly Pay

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 Employment	Gross Monthly Pay

4. How much cash do you and your spouse have? $_________________

Below, state any money you and your spouse have in bank accounts or in any other financial institution.

Financial Institution	Type of Account	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.

☐ Home	☐ Other real estate
Value ___________________	Value ___________________

☐ Motor Vehicle #1	☐ Motor Vehicle # 2
Year, Make, Model _______	Year, Make, Model _______
Value ___________________	Value ___________________

☐ 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 your spouse money		Amount owed to you	Amount owed to your spouse

7. State the persons who rely on you or your spouse for support.

Name		Relationship	Age

8. Estimate the average monthly expenses of you and your spouse. 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? ☐ Yes ☐ No
Is property insurance included? ☐ Yes ☐ No
Utilities (electricity, heating fuel, Water, sewer, and telephone)
Home Maintenance (repairs and upkeep)
Food
Clothing
Laundry and Dry-Cleaning
Medical and Dental Expenses
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 Vehicles
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?

☐ Yes ☐ 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?

☐ Yes ☐ 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?

☐ Yes ☐ 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)

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ITEM 21D | SAMPLE MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

No. ______________

IN THE SUPREME COURT OF THE UNITED STATES

_ — PETITIONER
(Your Name)
vs.
__________ — RESPONDENT(S)

MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

AFFIDAVIT OR DECLARATION
IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

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ITEM 21D | SAMPLE MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

No. ________________________ IN THE SUPREME COURT OF THE UNITED STATES _____________________ — PETITIONER (Your Name) vs. ____________________ — RESPONDENT(S) MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

AFFIDAVIT OR DECLARATIONIN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

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add a comment

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That Will Test Another User's Page-Specific Knowledge

No. ______________

IN THE SUPREME COURT OF THE UNITED STATES

_ — PETITIONER
(Your Name)
vs.
__________ — RESPONDENT(S)

MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

AFFIDAVIT OR DECLARATION
IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

Pages That You
Might Also Like

thank you, come again!
TBD 1.037