XYZ Commission, Respondent. ) (here name all parties bringing the petition)* hereby petition the court for review of the Order of the XYZ Commission (describe the order) entered on ____________________, 20___. (s) __________________________________ Attorney for Petitioners __________________ Address: _____________________________ * See Rule 15 Form 4. Affidavit Accompanying Motion for Permission to Appeal In Forma Pauperis United States District Court for District of A.B., Plaintiff v. Case No.: _______________________ C.D., Defendant Affidavit in Support of Motion I swear or affirm under penalty of perjury that, because of my poverty, I cannot prepay the docket fees of my appeal or post a bond for them. I believe I am entitled to redress. I swear or affirm under penalty of perjury under United States laws that my answers on this form are true and correct. (28 U.S.C. § 1746; 18 U.S.C § 1621.) Signed: ________________________ Instructions Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is “0,” “none,” or “not applicable (N/A),” write in that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name, your case’s docket number, and the question number. Date: __________________________ My issues on appeal are: 1. For both you and your spouse estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. Average monthly amount during the past 12 months Amount expected next month Income Source You Spouse You Spouse Employment $ $ $ $ Self-Employment $ $ $ $ Income from real property (such as rental income) $ $ $ $ Interest and dividends

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