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AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
UNITED STATES DISTRICT COURT
__________ District of __________
Civil Action No.
APPLICATION TO PROCEED IN DISTRICT COURT 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.
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.
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
Income amount expected
You Spouse You Spouse
Income from real property
(such as rental income)
Interest and dividends