Miss. R. App. P., app 1, form Form 4
IN THE ___________ COURT OF THE ________ JUDICIAL
DISTRICT OF ____________ COUNTY, MISSISSIPPI
STATE OF MISSISSIPPI
NO. ________
VS.
________________________
AFFIDAVIT TO ACCOMPANY MOTION FOR LEAVE TO
APPEAL 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 because of my poverty I am unable to pay the fees and costs of this proceeding and that I believe 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 andgive the name and address of your employer.
_________________________________
_________________________________
_________________________________
_________________________________
b. If the answer is no, state the date of your last employment and the amount of thesalary 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 amountreceived from each during the past twelve months. ____________________________
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 becaptioned "In the Supreme Court of Mississippi."
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 relationshipto those persons.
______________________________
______________________________
______________________________
______________________________
I understand that a false statement or answer to any question or instruction in thisaffidavit will subject me to penalties for perjury.
__________________________
Signature of Applicant
STATE OF _____________________
COUNTY OF _____________________
SUBSCRIBED AND SWORN TO before me this __________ day of ______________, 19______.
________________________________
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."
Miss. R. App. P., app 1, form Form 4