Fill and Sign the In the Court of Appeals of the State of Mississippi Barry Form

IN THE CIRCUIT COURT OF THE ________________ JUDICIAL DISTRICT OF ________________ COUNTY, MISSISSIPPI STATE OF MISSISSIPPI VS. NO. ________________ ________________ AFFIDAVIT TO ACCOMPANY MOTION FOR LEAVE TOAPPEAL IN FORMA PAUPERIS I, ________________ , being first duly sworn, depose and say that I am the ________________ in this case; that ________________ , ________________ in support of my motion to proceed on appeal without being required to prepay fees and costs, I state that be cause of my poverty I am unable to pay the fees and costs of this proceeding and that I belie ve I am entitled to redress. I further swear that the responses which I have made to the question and instructions below relating to my ability to pay the fees and costs of prosecuting the appeal are true. 1. Are you presently employed? a. If the answer is yes, state the amount of your salary and wages per month and give the name and address of your employer. b. If the answer is no, state the date of your last employment and the amount of the salary and wages per month which you received. 2. 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 rental 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 twelve 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 yes, describe the property and state its approximate value. 5. List the persons who are dependent upon you for support and state your relationship to those persons. I understand that a false statement or answer to any question or instruction in this affidavit will subject me to penalties for perjury. __________________________ Signature of Applicant STATE OF COUNTY OF SUBSCRIBED AND SWORN TO before me this ____ day of _______________ , 20__. _____________________________ Notary Public MY COMMISSION EXPIRES *An affidavit filed in the Supreme Court accompanying an application under M.R.A.P. 22 for post-conviction collateral relief after an appeal has been affirmed or dismissed should be captioned "In the Supreme Court of Mississippi.