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Name of your Court:

Name of Your State:

Plaintiff Name:

Plaintiff Attorney Name:

Defendant Name:

Defendant Attorney Name:

Case Number:

Title of Your Motion:

Petition to File in Forma Pauperis and Affidavit of Poverty

Comes now the plaintiff, Lee Allen Martin, and does request that the Notice of Appeal of Case # 01CV324209 be filed in forma pauperis, or as a poor person, with leave of this honorable court without the filing fee, pursuant to RSMo 514.040 and Mo S. Ct. Rule 81.04(c). Further, plaintiff does swear and affirm that he is without means to pay the filing fee in this proceeding because of his impoverished state. Plaintiff is not employed. Plaintiff did file a 1997 tax return showing that no income was made in the tax year aforementioned. Plaintiff has attached said tax returns. Plaintiff has not filed income tax returns for any later year.
Put your statement in here. Below is an example of what I have submitted as a appeals statement. You should consult your statutes, and rules of court for your particular appellant rules.

Therefore, plaintiff must request that the Notice of Appeal be filed by this honorable court pursuant to Mo. S. Ct. Rule 81.04(c) without the filing fee, or in the alternative that an evidentiary hearing to determine the impoverished state of the plaintiff be granted.
This is your PRAYER (as if you got one). The prayer is a legal term tell the court what you want it to do. Please do not ask the court to do more than it has authority to do, but do not ask for less. You have a long hard battle in front of you and by the time you get to the end you will want cost and maybe some hide.

Respectfully Submitted,

CERTIFICATE OF SERVICE

I hereby certify this pleading was served upon all attorneys of record for each of the parties to this action and All parties not represented by counsel, in the following manner:
___ By delivering a copy to him/her;
___ By leaving a copy at his/her office with the clerk;
___ By leaving a copy at his/her office with an attorney associated with him/her;
___ By mailing a copy to him/her, as prescribed by law;
___ By faxing a copy to him/her.

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