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United States Court of Appeals

Eighth Circuit

)

Appeal No.

Plaintiff/Petitioner

v.

District Court or Agency No.

Defendant/Respondent

APPLICATION TO PROCEED WITHOUT PREPAYING FEES OR COSTS

Affidavit in Support of the Application

I am a plaintiff or petitioner in this case and declare

that I am unable to pay the costs of these proceedings

and that I am entitled to the relief requested. I declare

under penalty of perjury that the information below is

true and understand that a false statement may result in

a dismissal of my claims.

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 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.

Signed:

Date:

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.

Income source

Average monthly income

amount during the past 12

months

Income amount expected

next month

You

Spouse

You

Spouse

Employment

$

Self-employment

$

Income from real property (such as rental income)

$

Interest and dividends

$

Gifts

$

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Alimony

$

Child support

$

Retirement (such as social security, pensions, annuities,

insurance)

$

Disability (such as social security, insurance payments)

$

Unemployment payments

$

Public-assistance (such as welfare)

$

Other (specify):

$

Total monthly income:

$

2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or

other deductions.)

Employer

Address

Dates of employment

Gross

monthly pay

$

3. List your spouse's employment history for the past two years, most recent employer first. (Gross monthly pay is before

taxes or other deductions.)

Employer

Address

Dates of employment

Gross

monthly pay

$

4. How much cash do you and your spouse have? $

Below, state any money you or your spouse have in bank accounts or in any other financial institution.

Financial institution

Type of account

Amount you have

Amount your

spouse has

$

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If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts,

expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts,

perhaps because you have been in multiple institutions, attach one certified statement of each account.

5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household

furnishings.

Assets owned by you or your spouse

Home (Value)

$

Other real estate (Value)

$

Motor vehicle #1 (Value)

$

Make and year:

Model:

Registration #:

Motor vehicle #2 (Value)

$

Make and year:

Model:

Registration #:

Other assets (Value)

$

Other assets (Value)

$

6. State every person, business, or organization owing you or your spouse money, and the amount owed.

Person owing you or your spouse

money

Amount owed to you

Amount owed to your spouse

$

7. State the persons who rely on you or your spouse for support.

Name (or, if under 18, initials only)

Relationship

Age

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8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your

spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the

monthly rate.

You

Your spouse

Rent or home-mortgage payment (including lot rented for mobile home)

$

Are real estate taxes included?

Yes

No

Is property insurance included?

Yes

No

Utilities (electricity, heating fuel, water, sewer, and telephone)

$

Home maintenance (repairs and upkeep)

$

Food

$

Clothing

$

Laundry and dry-cleaning

$

Medical and dental expenses

$

Transportation (not including motor vehicle payments)

$

Recreation, entertainment, newspapers, magazines, etc.

$

Insurance (not deducted from wages or included in mortgage payments)

Homeowner's or renter's:

$

Life:

$

Health:

$

Motor vehicle:

$

Other:

$

Taxes (not deducted from wages or included in mortgage payments) (specify):

$

Installment payments

Motor vehicle:

$

Credit card (name):

$

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Department store (name):

$

Other:

$

Alimony, maintenance, and support paid to others

$

Regular expenses for operation of business, profession, or farm (attach detailed

statement)

$

Other (specify):

$

Total monthly expenses:

$

9. Do you expect any major changes to your monthly income or expenses or in your assets

or liabilities during the

next 12 months?

Yes

No

If yes, describe on an attached sheet.

10. Have you spent — or will you be spending — any money for expenses or attorney fees in conjunction with this

lawsuit?

Yes

No

If yes, how much?

$

11. Provide any other information that will help explain why you cannot pay the costs of these proceedings.

12. Identify the city and state of your legal residence.

Your daytime phone number:

Your age:

Your years of schooling:

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