Form 3

IN THE SUPREME COURT OF THE STATE OF MONTANA

Supreme Court Cause No.__________

_________________________________,

Plaintiff/Petitioner and

☐ Appellant or ☐ Appellee,

v.MOTION AND AFFIDAVIT    

TO PROCEED ON APPEAL WITHOUT    

PAYMENT OF FILING FEE    

_________________________________,

Defendant/Respondent and

☐ Appellant or ☐ Appellee.

I move this Court to proceed without payment of the filing fee in this cause, and I submit this Affidavit in support of my motion.

I, ________________________________, being first duly sworn, depose and say that I am the _____________ (designation of party) in the above-entitled cause; that in support of my application to proceed on appeal without being required to pay the filing fee, I state that because of my financial condition I am unable to pay the filing fee; that I believe I am entitled to redress; and that the issues which I desire to present on appeal are the following:

I further swear that the responses which I have made to the questions and instructions below relating to my ability to pay the cost of prosecuting the appeal are true.

1. Are you presently employed? _______

a. If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer.

b. If the answer is no, state the date of your last employment and the amount of the salary and wages per month which you received.

2. Have you received within the past 12 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 12 months.

3. Do you own any cash or checking or savings account? 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)? 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 relationship to those persons.

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

____________________________________

Subscribed and sworn to before me this _____day of _____________, 20___.

SEAL___________________________________

Notary Public for the State of Montana

Residing at _________________________

My Commission expires _______________