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UNITED STATES SUPREME COURT

[plfName]	)
Petitioner,	)
)
vs.	)
)
[defName]	)	Case No
Respondent,	)	__-____

MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

Petitioner asks for 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:

Petitioner has previously been granted leave to proceed in forma pauperis in the following courts:
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.
Petitioner’s affidavit or declaration is not attached because the court below appointed counsel in the current proceeding, and:
The appointment was made under the following provision of law:
OR
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, [plfName], 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.

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:	$	$	$	$

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
$
$

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
$
$

How much cash do you and your spouse have? $10

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

Type of account (eg, checking or savings)	Amount You Have	Amount Your Spouse Has
$	$
$	$

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

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

State the persons who rely on you or your spouse for support. For minor children, list initials instead of names (eg “J.S.” instead of “John Smith”).

Name	Relationship	Age

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? 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 Vehicle	$	$
Credit Cards	$	$
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:	$	$

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.

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:

Name	Address	Phone Number

Have you paid – or will you be paying – anyone other than an attorney (such as a paralegal or a typist) any money in connection with this case, including the completion of this form?

Yes No

If yes, how much? ________________________________

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: [sigDt]

(Signature)

Template:

TextBookDiscrimination.com/Templates/USSC/0b_Miscellaneous_001_Indigence.dotx

How-To Guide (Petition for Writ of Certiorari)

TextBookDiscrimination.com/Guides/Petitions/Certiorari

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