Name/Address of Attorney or Pro Per

Telephone

□ FPD □ Apptd □ CJA □ Pro Per
UNITED STATES DISTRICT COURT

CENTRAL DISTRICT OF CALIFORNIA

PLAINTIFF(S),

v.

DEFENDANT(S).	CASE NUMBER:

Motion and Affidavit for Leave to Appeal In Forma Pauperis:	□ 28 U.S.C. 753(f)

□ 28 U.S.C. 1915

The undersigned	, a party in the within action, moves the Court under 28 USC § 1915 for authorization to prosecute an appeal without prepayment of fees and costs or security therefor, and for the preparation of a Court Reporter's transcript at government expense.

1.	I believe I am entitled to redress, and the issues which I desire to present on my proposed appeal are the following:

a.

b.

c.

2.	Because of my poverty I am unable to pay the costs of the proposed appeal proceeding or to give security therefor. I swear that the following responses are true.

a.	Are you presently employed? □ Yes □ No. If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer.

b.	Have you received, within the past twelve months, any income from a business, profession or other form of self-
employment, or in the form of rent payments, interest, dividends, or other source? □ Yes □ No.

If the answer is yes, describe each source of income and state the amount received from each during the past twelve months.

c.	Are you presently employed in prison?	□ Yes □ No.

If yes, state the number of hours you work per week and the hourly rate of pay.

d.	Do you own any cash or do you have money in a checking or savings account? □ Yes □ No.

If the answer is yes, state the amount of money in each account separately as of six (6) months prior to the date of this affidavit.

e.	Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)?

f.	In what year did you last file an income tax return?

g.	Approximately how much income did your last tax return reflect?

h.	List the persons who are dependent upon you for support and state your relationship to those persons.

i.	State monthly expenses, itemizing the major items.

I declare under penalty of perjury that the foregoing is true and correct.

Signature of Party

Date	Signature of Attorney

(Disregard if filed in propria persona)