Application To Proceed In District Court Without Prepaying (Short Form For Prisoner Cases) {AO 240}

AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form) UNITED STATES DISTRICT COURTfor the District of )))))Plaintiff/Petitionerv.Civil Action No. Defendant/Respondent APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Short Form) I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings andthat I am entitled to the relief requested.In support of this application, I answer the following questions under penalty of perjury:1.If incarcerated. I am being held at:.If employed there, or have an account in the institution, I have attached to this document a statement certified by theappropriate institutional officer showing all receipts, expenditures, and balances during the last six months for anyinstitutional account in my name. I am also submitting a similar statement from any other institution where I wasincarcerated during the last six months.2.If not incarcerated. If I am employed, my employer222s name and address are:My gross pay or wages are: $, and my take-home pay or wages are: $per (specify pay period).3.Other Income. In the past 12 months, I have received income from the following sources (check all that apply):(a) Business, profession, or other self-employmentYesNo(b) Rent payments, interest, or dividendsYesNo(c) Pension, annuity, or life insurance paymentsYesNo(d) Disability, or worker222s compensation paymentsYesNo(e) Gifts, or inheritancesYesNo(f) Any other sourcesYesNoIf you answered 223Yes224 to any question above, describe below or on separate pages each source of money andstate the amount that you received and what you expect to receive in the future. American LegalNet, Inc. www.FormsWorkFlow.com AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)4. Amount of money that I have in cash or in a checking or savings account: $.5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument orthing of value that I own, including any item of value held in someone else222s name (describe the property and its approximatevalue):6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and providethe amount of the monthly expense):7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationshipwith each person, and how much I contribute to their support:8. Any debts or financial obligations (describe the amounts owed and to whom they are payable):Declaration: I declare under penalty of perjury that the above information is true and understand that a falsestatement may result in a dismissal of my claims.Date:Applicant222s signaturePrinted name American LegalNet, Inc. www.FormsWorkFlow.com