HRAP Form 4 "Affidavit in Support of Motion for Leave to Proceed on Appeal in Forma Pauperis" - Hawaii

Form HRAP4 or the "Affidavit In Support Of Motion For Leave To Proceed On Appeal In Forma Pauperis" is a form issued by the Hawaii State Judiciary.

Download a PDF version of the Form HRAP4 down below or find it on the Hawaii State Judiciary Forms website.

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Download HRAP Form 4 "Affidavit in Support of Motion for Leave to Proceed on Appeal in Forma Pauperis" - Hawaii

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IN THE
OF THE STATE OF HAWAII
)
CASE NO.
)
,
)
)
Plaintiff,
)
v.
)
)
,
)
)
Defendant.
)
AFFIDAVIT IN SUPPORT OF MOTION FOR LEAVE
TO PROCEED ON APPEAL IN FORMA PAUPERIS
)
STATE OF HAWAII
)
SS.
)
)
COUNTY OF
)
being first duly sworn, depose
I,
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,
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; and that
the issues which I desire to present on appeal are the following:
I further state 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.
RG-LC-508 (10/2016)
SC-P-343
1
HRAP Form 4 (09/10)
IN THE
OF THE STATE OF HAWAII
)
CASE NO.
)
,
)
)
Plaintiff,
)
v.
)
)
,
)
)
Defendant.
)
AFFIDAVIT IN SUPPORT OF MOTION FOR LEAVE
TO PROCEED ON APPEAL IN FORMA PAUPERIS
)
STATE OF HAWAII
)
SS.
)
)
COUNTY OF
)
being first duly sworn, depose
I,
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,
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; and that
the issues which I desire to present on appeal are the following:
I further state 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.
RG-LC-508 (10/2016)
SC-P-343
1
HRAP Form 4 (09/10)
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 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?
a.
If the answer is yes, describe each source of income, and state the
amount received from each during the past twelve months.
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.
2
HRAP Form 4 (09/10)
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 questions in this affidavit will
subject me to penalties for perjury.
Subscribed and sworn to before me
this
day of
, 20
.
Notary Public, State of Hawaii
My commission expires:
[ ] Application granted.
[ ] Application denied for the following reason:
[ ] Appeal is not taken in good faith.
[ ] Applicant does not meet financial qualifications.
Judge/Justice of the above-entitled court
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3
HRAP Form 4 (09/10)
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