Fill and Sign the Affidavit Pauperis Form

Name:______________________ Address:____________________ ___________________________ ___________________________ IN THE SUPREME COURT OF THE STATE OF MONTANA Cause No................ ) ..........................................., ) Plaintiff/Petitioner and Appellant/Respondent ) MOTION AND AFFIDAVIT ) TO PROCEED IN FORMA ) PAUPERIS vs. ) ) ............................................., ) Defendant/Respondent and Appellant/Respondent. ) ____________________ Comes now,________________________, the _______________________ in the above-entitled cause and moves the Supreme Court to proceed in forma pauperis . In support of my motion, I, ________________________, being first duly sworn, depose and say; that because of my poverty I am unable to pay the costs of said proceeding or give security; that I believe I am entitled to redress; and that the issues which I desire to present to this court are the following:_____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. I further 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. 1. Are you presently employed?__________________________________________ a. If the answer is yes, state the amount of your salary or wages per month and give the name and address of you employer. ___________________________ __________________________________________________________________ b. If the answers is no, state the date of you last employment and the amount of the salary wages per month which you received. ____________________________________________________________ ____________________________________________________________ 2. Have you received within the past 12 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? a. If the answer is yes, describe each source of income, and state the amount received from each during the past 12 months. 3. Do you own any cash or checking or savings account? ______________________ a. If the answer is yes, state the total value of the items owned.___________ 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? ____________ __________________________________________________________________ a. If the answer is year, describe the property and state its approximate value. ____________________________________________________________ ____________________________________________________________ 5. List the persons who are dependent upon you for support and state your relations to those persons. ___________________________________________________ _________________________________________________________________ I understand that a false statement or answer to any question in this motion and affidavit will subject me to penalties for perjury. ____________________________ (signature) Subscribed and Sworn to before me this ________ day of ____________, 200__. _____________________ Notary Public (SEAL)