_____ Yes _____ No If yes, describe on an attached sheet. 10. Have you paid – or will you be paying – an attorney any money for services in connection with this case, including the completion of this form? _____ Yes _____ No If yes, how much? $_________________________ If yes, state the attorney’s name, address, and telephone number. _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 11. Have you paid – or will you be paying – anyone other than an attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion of this form? _____ Yes _____ No If yes, how much? $_________________________ If yes, state the person’s name, address, and telephone number. _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 12. Provide any other information that will help explain why you cannot pay the docket fees for your appeal. _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 13. State the address of your legal residence. _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Your daytime phone number: (______)____________________ Your age: _______________ Your years of schooling: _____________________ Your social security number: _____________________ Form 5. Notice of Appeal to a Court of Appeals from a Judgment or Order of a District Court or a Bankruptcy Appellate Panel United States District Court for the __________ District of __________ In re ) ) ____________________________ ) Debtor ) ) ____________________________ ) Plaintiff ) File No. ______________ )

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