Application To Proceed Without Prepayment Of Fees And Costs (LRCivP3.5)

UNITED STATES DISTRICT COURTSouthernDistrict of West Virginia, Division:APPLICATION TO PROCEEDWITHOUT PREPAYMENT OF FEES AND COSTS v.CASE NUMBER:I,declare that I am the (check appropriate box)Gplaintiff/petitioner/movant G appellantG otherin the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costsunder 28 U.S.C. 2471915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to therelief sought in the complaint/petition/motion/notice of appeal.In support of this application, I answer the following questions under penalty of perjury:1.Are you currently incarcerated? GYes(If 223Yes,224 go to # 3) G No(If 223No,224 go to # 2)If 223Yes,224 state the place of your incarcerationAre you employed at the institution? Do you receive any payment from the institution?Have the institution fill out the Certificate portion of this application and attach a ledger sheet from theinstitution(s) of your incarceration showing at least the past six months222 transactions.2.Are you currently employed?Yes (If 223Yes,224 go to # 2.a) G No (If 223No,224 go to # 2.b)a.If the answer is 223Yes,224 state the amount of your take-home salary or wages and pay period and give thename and address of your employer.b.If the answer is 223No,224 state the date of your last employment, the amount of your take-home salary or wagesand pay period and the name and address of your last employer.3.In the past 12 twelve months have you received any money from any of the following sources?a.Business, profession or other self-employmentGYesGNob.Rent payments, interest or dividendsGYesGNoc.Pensions, annuities or life insurance paymentsGYesGNod.Disability or workers compensation paymentsGYesGNoe.Gifts or inheritancesGYesGNof.Any other sourcesGYesGNoIf you answered 223Yes224 to any portion of question #3, describe each source of money and state the amountreceived and what you expect you will continue to receive. American LegalNet, Inc. www.FormsWorkFlow.com 4.Do you have any cash or checking or savings accounts?GYesGNoIf 223Yes,224 state the total amount.5.Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any otherthing of value?GYesGNoIf 223Yes,224 describe the property and state its value.6.List the persons who are dependent on you for support, state your relationship to each person and indicatehow much you contribute to their support.7.I do hereby stipulate that the recovery, if any, obtained in this action shall be paid to the Clerk of Court, whoshall pay therefrom, all unpaid costs taxed against plaintiff and pay the balance to plaintiff and/or his/herattorney, if any.I declare under penalty of perjury that the above information is true and correct.DateSignature of ApplicantCERTIFICATE(Incarcerated applicants only)(To be completed by the institution of incarceration)I certify that the applicant named herein has the sum of $ on account to his/her creditat (name of institution) . I further certify that the applicant has thefollowing securities to his/her credit .I further certify that during the past six months the applicant222s average balance was $ , and theaverage of monthly deposits was $ .DateSignature of Authorized Officer American LegalNet, Inc. www.FormsWorkFlow.com