Fill and Sign the Motion and Affidavit for Proceeding in Forma Court Forms

IFP201 State ENG Rev 07/15 www.mncourts.gov/forms Page 1 of 2 State of Minnesota District Court County Judicial District: Court File Number: Case Type: Plaintiff/ Petitioner Affidavit for Proceeding In Forma Pauperis (Inmate) vs. (Minn. Stat. §§ 563.01, 563.02 ) Defendant/Respondent STATE OF MINNESOTA ) ) SS COUNTY OF ) (County where Affidavit signed) 1. I am a party in this action. I am not represented by counsel, I have been convicted of a felony a nd I am committed to the custody of the Commissioner of C orrections . I am either confined in a state correctional facility or I have been released from a state correctio nal facility under section Minn. Stat. §§ 244.065 or 244.07 . 2. I believe I have valid reasons for pursuing this action. In good faith, I request an order waiving court fees and costs. My pleadings (the Petition , Complaint , Answer , Appeal or other pleading) are attached. NOTE: If you are the person bringing the case, known as the plainti ff, the statute requires you provide the court with a copy of the Complaint before serving the complaint on the opposing party. 3. The follo wing information is required. You must complete each section. a. I have the following dependents: b. My net (ta ke home) monthly income is $ . c. The source of my monthly income is d. If available to you, your spouse’s net (take home) monthly income is $ e. I pay $ per month in child care support. f. I pay $ per month for rent/mortgage payment. g. I own the f ollowing property: 1) Cash $ 2) Checking, savings and credit union accounts $ 3) Cars, other vehicles [list make, year, and equity value (market value minus unpaid loans) for each] a) $ b) $ IFP201 State ENG Rev 07/15 www.mncourts.gov/forms Page 2 of 2 4) Real e state a) $ b) $ 5) Other pers onal property (jewelry, stock, bonds, etc. – list separately) a) $ b) $ h. I am presently $ ______________________ in debt. i. I have the following monthly expenses: j. Other factors which support this are: (explain unusual medical expenses, emergencies or other circumstances to help the judge understand your situation): 6. I have exhausted the inmate complaint procedure developed by the Commissioner of Corrections before commencing this action against the Department of Corrections. 7. My claim is not substantially similar to a previous claim brought against the same party , arising from the same facts , and which resulted in an adjudication on the merits. 8. My full name is and I have been known by the following other names: 9. I have attached a copy of my most recent monthly statement showing the balance in my inmate account. I authorize the Court to obtain at any time during the pendency of this action a current statement of the b alance of my inmate account. NOTE: An inmate who has funds in an inmate account may only proceed as a plaintiff in a civil action by paying either the applicable court filing fee or 5 0% of the balance in the inmate account, whichever is less. If 50% of balance of the inmate account is used to commence the civil action, the Commissioner of Corrections will continue to draw money out of the inmate account until the filing fee is paid in full. By signing this Affidavit, I am certifying that these statements are true under penalty of perjury. I understand that if I provide false information on the form it may lead to criminal charges. I understand that failure to execute the form or failu re to provide information or requested records may result in denial of my motion to proceed In Forma Pauperis. I am authorizing that the facts contained in this Affidavit may be verified by any means required. Dated: Signature Name: Address: City/State/Zip: Telephone: ( ) E-mail address: