AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)
UNITED STATES DISTRICT COURT
for the
__________ District of __________
)
)
)
)
)
Plaintiff/Petitioner
v.
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 and
that 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 the
appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any
institutional account in my name. I am also submitting a similar statement from any other institution where I was
incarcerated during the last six months.
2. If not incarcerated. If I am employed, my employer’s 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-employment
’
Yes
’
No
(b) Rent payments, interest, or dividends
’
Yes
’
No
(c) Pension, annuity, or life insurance payments
’
Yes
’
No
(d) Disability, or worker’s compensation payments
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Yes
’
No
(e) Gifts, or inheritances
’
Yes
’
No
(f) Any other sources
’
Yes
’
No
If you answered “Yes” to any question above, describe below or on separate pages each source of money and
state the amount that you received and what you expect to receive in the future.
