28 USC App, FEDERAL RULES OF APPELLATE PROCEDURE, Form 4: Affidavit to Accompany Motion for Leave to Appeal in Forma Pauperis
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*Public Law 119-75 has been enacted, but classifications have not been finalized. The currency ("laws in effect") date does not reflect acts for which classifications have not been finalized.

28 USC App, FEDERAL RULES OF APPELLATE PROCEDURE, Form 4: Affidavit to Accompany Motion for Leave to Appeal in Forma Pauperis
From Title 28-AppendixFEDERAL RULES OF APPELLATE PROCEDUREAPPENDIX OF FORMS

Form 4. Affidavit to Accompany Motion for Leave to Appeal in Forma Pauperis

(As amended Apr. 24, 1998, eff. Dec. 1, 1998.)