(Title)I.........,
the above-named, present the accompanying memorandum of appeal from the decree
in the above suit and apply to be allowed to appeal as a pauper.Annexed
is a full and true schedule of all the movable and immovable property belonging
to me with the estimated value thereof.Dated
the .........day of ........19...........(Signed.)Note--
Where the application is by the plaintiff he should state whether he applied
and was allowed to sue in the Court of first instance as a pauper.