Form 4 "Declaration to Accompany Motion for Leave to Appeal in Forma Pauperis" - Hawaii

What Is Form 4?

This is a legal form that was released by the Hawaii State Judiciary - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 4, 2020;
  • The latest edition provided by the Hawaii State Judiciary;
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Download Form 4 "Declaration to Accompany Motion for Leave to Appeal in Forma Pauperis" - Hawaii

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Electronically Filed
Supreme Court
SCRU-10-0000012
04-AUG-2020
09:33 AM
SCRU-10-0000012
ʻ
IN THE SUPREME COURT OF THE STATE OF HAWAI
I
In the Matter of the
ʻ
HAWAI
I RULES OF APPELLATE PROCEDURE
ORDER AMENDING RULE 24 AND FORM 4
ʻ
OF THE HAWAI
I RULES OF APPELLATE PROCEDURE
1
(By: Recktenwald, C.J., Nakayama, McKenna, and Wilson, JJ.)
ʻ
IT IS HEREBY ORDERED that Rule 24 of the Hawai
i Rules
of Appellate Procedure is amended, effective immediately upon
the entry of this order, as follows (deleted material is
bracketed and stricken, new material is underscored):
Rule 24.
PROCEEDINGS IN FORMA PAUPERIS.
(a) Leave to proceed on appeal in forma pauperis from a
[the circuit, district, family, land, environmental, or tax appeal]
court or [from an] agency determination to the Hawaiʻi appellate
courts. A motion for leave to proceed on appeal in forma pauperis from
[the circuit, district, family, land, environmental, or tax appeal] a court[,]
or [from an ]agency determination[,] shall ordinarily be made in the first
instance to the court or agency appealed from.
1
Associate Justice Richard W. Pollack, who participated in the consideration
of these amendments, retired on July 1, 2020.
Electronically Filed
Supreme Court
SCRU-10-0000012
04-AUG-2020
09:33 AM
SCRU-10-0000012
ʻ
IN THE SUPREME COURT OF THE STATE OF HAWAI
I
In the Matter of the
ʻ
HAWAI
I RULES OF APPELLATE PROCEDURE
ORDER AMENDING RULE 24 AND FORM 4
ʻ
OF THE HAWAI
I RULES OF APPELLATE PROCEDURE
1
(By: Recktenwald, C.J., Nakayama, McKenna, and Wilson, JJ.)
ʻ
IT IS HEREBY ORDERED that Rule 24 of the Hawai
i Rules
of Appellate Procedure is amended, effective immediately upon
the entry of this order, as follows (deleted material is
bracketed and stricken, new material is underscored):
Rule 24.
PROCEEDINGS IN FORMA PAUPERIS.
(a) Leave to proceed on appeal in forma pauperis from a
[the circuit, district, family, land, environmental, or tax appeal]
court or [from an] agency determination to the Hawaiʻi appellate
courts. A motion for leave to proceed on appeal in forma pauperis from
[the circuit, district, family, land, environmental, or tax appeal] a court[,]
or [from an ]agency determination[,] shall ordinarily be made in the first
instance to the court or agency appealed from.
1
Associate Justice Richard W. Pollack, who participated in the consideration
of these amendments, retired on July 1, 2020.
A party to an action in [the circuit, district, family, land,
environmental, or tax appeal] a court[,] or [before an] administrative
agency who desires to proceed on appeal in forma pauperis may file in
the appellate court a motion for leave to so proceed. The motion shall be
accompanied by a[n affidavit or] declaration, showing, in the detail
prescribed by Form 4 in [of] the Appendix of Forms of these Rules, the
party’s inability to pay the required filing fees or to give security for
costs and[,] the party's belief that the party[he or she] is entitled to
redress, and a statement of the issues that the party intends to present on
appeal]. [If the appeal is from a court,]T[t]he motion shall show that
application to the court or agency appealed from for the relief sought is
not practicable, or that the court or agency appealed from has denied an
application, or has failed to afford the requested relief, with the reasons
given by the court or agency appealed from for its action. A party who
has filed such a motion may file [his or her]the notice of appeal without
being required to prepay the filing fees. If the motion is granted, the
party may proceed with the appeal without prepayment of fees or costs or
the giving of security therefor.
(b) Effect of prior leave to proceed in forma pauperis.
Notwithstanding the provisions of the preceding paragraph, a party who
has been permitted to proceed in an action in a court or agency in forma
pauperis, or who has been permitted to proceed as one who is financially
unable to obtain adequate defense in a criminal case, may proceed on
appeal in the same action in forma pauperis without further authorization
unless, before or after the notice of appeal is filed, the court or agency
[shall certify that the appeal is not taken in good faith or shall] finds that
the party is otherwise not entitled so to proceed, in which event the court
or agency shall state in writing the reasons for such [certification or]
finding.
(c) Effect of denial of motion for leave to proceed in forma
pauperis. If the motion to proceed in forma pauperis is denied, the
movant shall, within 10 days after the denial of such a motion, pay all
unpaid filing fees and shall give security for costs. Failure of the
unsuccessful movant to pay the unpaid filing fees or to give security for
costs shall not affect the validity of the appeal, but is ground for such
action as the appellate court having jurisdiction over the appeal deems
appropriate, and may include dismissal of the appeal.
IT IS FURTHER ORDERED that Form 4, attached hereto, is
ʻ
adopted and shall be appended to the Hawai
i Rules of Appellate
2
Procedure in place of the previous Form 4, effective immediately
upon the entry of this order.
ʻ
DATED:
Honolulu, Hawai
i, August 4, 2020.
/s/ Mark E. Recktenwald
/s/ Paula A. Nakayama
/s/ Sabrina S McKenna
/s/ Michael D. Wilson
3
Form 4.
Declaration to Accompany Motion for Leave to Appeal In Forma Pauperis.
IN THE (INTERMEDIATE COURT OF APPEALS or SUPREME COURT)
STATE OF HAWAIʻI
A.B., Plaintiff,
)
COURT OR AGENCY CASE NO. ____________
)
v.
)
)
C.D., Defendant.
)
)
DECLARATION IN SUPPORT OF MOTION FOR LEAVE
TO PROCEED ON APPEAL IN FORMA PAUPERIS
I, ____________________________________ hereby declare 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, and
that I believe I am entitled to redress.
I further declare 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, under penalty of perjury.
1.
HAVE YOU REQUESTED TO PROCEED IN FORMA PAUPERIS IN THE COURT OR
AGENCY IN THE CASE NUMBER SET FORTH ABOVE?
a.
If the answer is yes, proceed to question 2.
b.
If the answer is no, explain why, then proceed to question 2:
2.
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.
(Rev. 08/04/20)
Page 1 of 2
3.
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, GOVERNMENT BENEFITS (for
example, welfare, food stamps, Social Security, workers’ compensation, or unemployment
benefits) OR OTHER SOURCES?
a.
If the answer is yes, describe each source of income, and state the amount received from
each during the past 12 months.
4.
DO YOU OWN ANY CASH OR CHECKING OR SAVINGS ACCOUNT?
a.
If the answer is yes, state the total value of the items owned.
5.
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.
6.
PROVIDE THE NUMBER OF PERSONS WHO ARE DEPENDENT UPON YOU FOR
FINANCIAL SUPPORT:
#. __________
7.
PROVIDE THE NUMBER OF PERSONS IN YOUR HOUSEHOLD:
#. __________
I understand that a false statement or answer to any questions in this declaration will subject me
to penalties for perjury.
DATED: ___________________, Hawaiʻi, ________________________________________.
_____________________________________
Signature of Declarant
_____________________________________
Printed Name of Declarant
[ ] Application granted.
[ ] Application denied for the following reason:
[ ] Applicant does not meet financial qualifications.
[ ] Other:
Judge/Justice of the above-entitled court
(Rev. 08/04/20)
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