Professional Documents
Culture Documents
Appellant or petitioner,lli9.1
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Appellee or Respondent,
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Instructions
Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is "0," "none," or "not applicable {N/A)," write in that response. If you need nore space to answer a question, attach a separate sheet of paper identified with your name, your case's docket number, and the question number.
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My issues on appeal are:
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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.
You
Spouse
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TOTAL MONTHLY
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2.
List your employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.)
Employer
Address
Dates of Emplyoment
From To
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3.
List your spouse's employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.)
Employer
Dates of Emplyoment
From
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4.
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Amount Your Spouse Has
Below, state any money you or your spouse have in bank accounts or in any other financial institution. Financial Institution Type of Account Amount You Have
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If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutuional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account .
5.
List the assets, and their values, which you own or your sopuse owns. Do not list clothing and ordinary household furnishing.
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Home
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Value
Value
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Registration
Value
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Registration
Value
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Other Assets
Value
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6.
State every person, business, or organization owing you or your spouse money, and the amount owed.
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7.
State the persons who rely on you or your spouse for support. If a dependent is a minor, list only the initials and not the full name.
Name
Relationship
Age
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.....................
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8.
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, semiannually, or annually to show the monthly rate. You Spouse
Rent or home-mortgage payment (include lot rented for mobile home) - Are real estate taxes included? rYes ri No - Is property insurance included? eYes
[J No
Utilities (electricity, heating fuel, water, sewer, and telephone) Home maintenance (repairs and upkeep)
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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: . . . .
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Alimony, maintenance, and support paid to others Regular expenses for the operation of business, profession, or farm (attach detailed statement) Other (specify)
I
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 I'lNo
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?
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If yes, state the attorney's name, address, and telephone number. Name Address City Telephone Number (ex., 4153558000) 11. State
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Zip Code
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Have you paid--or will you be paying--anyone other than attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion of this form?
CYes
!Xl No
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If yes, state the attorney's name, address, and telephone number. Name Address City
Zip Code
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12.
Provide any other information that will help explain why you cannot pay the docket fees for your appeal.
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City
State
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