Full Name of Party Filing Document      

Mailing Address (Street or Post Office Box)

City, State and Zip Code

Telephone

Email Address (if any)

IN THE DISTRICT COURT FOR THE 		 JUDICIAL DISTRICT
FOR THE STATE OF IDAHO, IN AND FOR THE COUNTY OF 				

						,
		Plaintiff,
	vs.

						,
		Defendant.
	
Case No. 					

MOTION AND AFFIDAVIT FOR  PERMISSION TO PROCEED ON PARTIAL PAYMENT OF COURT FEES (PRISONER)

IMPORTANT NOTICE:  Idaho Code § 31-3220A requires that you serve upon counsel for the county sheriff, the department of correction or the private correctional facility, whichever may apply, a copy of this motion and affidavit and any other documents filed in connection with this request.  You must file proof of such service with the court when you file this document.
 Plaintiff   Defendant asks to start or defend this case on partial payment of court fees, and certifies
1.  	This is an action for (type of case) 							.  I believe I am entitled to get what I am asking for.     
2.    I have not previously brought this claim against the same party or a claim based on the same operative facts in any state or federal court.   I have filed this claim against the same party or a claim based on the same operative facts in a state or federal court.  
3.  I am unable to pay all the court costs now.   I have attached to this affidavit a current statement of my inmate account, certified by a custodian of inmate accounts, that reflects the activity of the account over my period of incarceration or for the last twelve (12) months, whichever is less.
     4.  I understand I will be required to pay an initial partial filing fee in the amount of 20% of the greater of: (a) the average monthly deposits to my inmate account or (b) the average monthly balance in my inmate account for the last six (6) months.  I also understand that I must pay the remainder of the filing fee by making monthly payments of 20% of the preceding month’s income in my inmate account until the fee is paid in full.
5.  I verify that the statements made in this affidavit are true.   I understand that a false statement in this affidavit is perjury and I could be sent to prison for an additional fourteen (14) years.  

(Do not leave any items blank.  If any item does not apply, write “N/A”.  Attach additional pages if more space is needed for any response.)
IDENTIFICATION AND RESIDENCE:
Name: 						 Other name(s) I have used:																	
Address:												
How long at that address?					 Phone:				
Year and place of birth:										
DEPENDENTS:
I am  single  married.  If married, you must provide the following information:
Name of spouse: 											
													
My other dependents including minor children (use only initials and age to identify children) are:																																									
INCOME:
Amount of my income: $		 per  week  month
Other than my inmate account I have outside money from: 																			
My spouse’s income: $		 per  week  month.  
 
ASSETS:
List all real property (land and buildings) owned or being purchased by you.
										            
Your    					Legal
Address	City		State		Description			Value		Equity

List all other property owned by you and state its value.
Description (provide description for each item)							Value
Cash				
Notes and Receivables				
Vehicles				
Bank/Credit Union/Savings/Checking Accounts				
Stocks/Bonds/Investments/Certificates of Deposit				
Trust Funds				
Retirement Accounts/IRAs/401(k)s				
Cash Value Insurance				
Motorcycles/Boats/RVs/Snowmobiles				
Furniture/Appliances				
Jewelry/Antiques/Collectibles				
Description (provide description for each item)							
TVs/Stereos/Computers/Electronics				
Tools/Equipment				
Sporting Goods/Guns				
Horses/Livestock/Tack				
Other (describe)																
EXPENSES:  (List all of your monthly expenses.)																			  Average
Expense									     Monthly Payment
Rent/House Payment				
Vehicle Payment(s)				
Credit Cards (List last four digits of each account number.) 

Loans (name of lender and reason for loan)

Electricity/Natural Gas				
Water/Sewer/Trash				
Phone				
Groceries				
Clothing				
Auto Fuel				
Auto Maintenance				
Cosmetics/Haircuts/Salons				
Entertainment/Books/Magazines				
Home Insurance				

											  Average
Expense									     Monthly Payment
Auto Insurance				
Life Insurance				
Medical Insurance				
Medical Expense				
Other 				
				
MISCELLANEOUS:
How much can you borrow? $			  From whom? 				 When did you file your last income tax return?  		  Amount of refund: $			
PERSONAL REFERENCES:  (These persons must be able to verify information provided.)
Name				Address				Phone		Years Known

CERTIFICATION UNDER PENALTY OF PERJURY

I certify under penalty of perjury pursuant to the law of the State of Idaho that the foregoing is true and correct.

Date: 				

Typed/printed 		 				 	Signature