IN THE SUPREME COURT OF ARKANSAS OR ARKANSAS COURT OF APPEALS | |
______________ | PETITIONER |
V. | NO. ____ |
STATE OF ARKANSAS | RESPONDENT |
AFFIDAVIT IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS
I, _______________ , being first duly sworn, depose and say that I am the petitioner in the above entitled case; that in support of my motion to proceed without being required to prepay fees, costs or 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.
I further swear that the responses which I have made to questions and instructions below are true.
If the answer to any of the above is yes, describe each source of money and state the amount received from each during the past twelve months. _____________________________________
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If the answer is yes, state the total amount in each account.
_______________________________
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If the answer is yes, describe the property and state its approximate value. __________________
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_______________________
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Do you have any funds in the inmate welfare funds? Yes ____ No ____
If the answer is yes, state the total amount in such account and have the certificate found below completed by the authorized officer of the institution. __________________________________
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I understand that false statement or answer to any questions in this affidavit will subject me to penalties for perjury.
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Signature of Petitioner
STATE OF _____________
COUNTY OF _____________
Petitioner, _____________ , being first duly sworn under oath, presents that he/she has read and subscribed to the above and states that the information therein is true and correct.
SUBSCRIBED AND SWORN to before me this _____ day of ______________ , 20__.
____________________
Notary Public
My commission expires:
____________________
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CERTIFICATE
(To be completed by authorized officer of penal institution) I hereby certify that the petitioner herein, _______________ , has the sum of $ ______ on account to his/her credit at the _____________ institution where he/she is confined. I further certify that petitioner likewise has the following securities to his/her credit according to the records of said institution: ___________
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______________________________
Authorized Officer of Institution
Ark. R. Sup. Ct. & Ct. App. 6-6
Reporter's Notes, 2013 Amendment. The 2013 amendment added subsection (c) to clarify which court has jurisdiction to consider a request to proceed in forma pauperis.