Appellate Case Number 

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MOTION AND AFFIDAVIT IN SUPPORT OF 
MOTION FOR LEAVE TO APPEAL IN 
FORMA PAUPERIS 

State of Alabama 
Unified Judicial System 

 

 

orm ARAP - 15              Rev. 11 / 91 

 IN THE CIRCUIT COURT OF _____________________________________________, COUNTY 

STATE OF ALABAMA 

.   DEFENDANT 

  v

 

        Comes the defendant and moves the court for an order granting leave to appeal in forma pauperis and in support said 

motion makes the following affidavit: 

          I, __________________________________,being first duly sworn, depose and say that I am the ____________, in the 

above–entitled case; that in support of my motion to proceed on appeal without being required to prepay fees or costs or to 

give security therefor, I state that because of my poverty I am unable to pay the costs of said proceeding or to give security 

therefor; that I believe I am entitled to redress; and that the issues which desire to present on appeal are that following: 

        I  further  swear  that  the  responses  which  I  have  made  to  the  questions  and  instructions  below  relating  to  my  ability  to 

If the answer is yes, state the amount of your salary or wages per month and give the name and address on your employer. 
If the answer is no, state the date of your last employment and the amount of 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 rent payments, interest, dividends, or other source? 

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

. Do you own any cash or checking or savings account? 

a.      If the answer is yes, state the total value of the items you own. 

 
4.        Do  you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary 

 
household furnishings and clothing)? 

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

I understand that a false statement or answers to any questions in this affidavit will subject me to penalties for perjury. 
 

____________________________________________ 
 
 
Counsel for Defendant 

 

 

   ________________________________________________ 
   Defendant 

 

  3

 

. 

  5

 

a. 
b. 
 

a. 

UBSCRIBED AND SWORN TO before me this _________ day of ____________________________, __________. 

et the applicant proceed without prepayment of costs or fees or the necessity of giving security therefor. 

    

 

 

 

 

 

 

 

   Circuit  Judge 

 
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pay the cost of prosecuting the appeal are true. 

1.  Are you presently employed? 
 

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