Application To Proceed In Forma Pauperis - District Of Nevada printable pdf download

Application To Proceed In Forma Pauperis - District Of Nevada

United States District Court

DISTRICT OF NEVADA

APPLICATION TO PROCEED

Plaintiff/Petitioner,

IN FORMA PAUPERIS

CASE NUMBER:

Defendant/Respondent,

, declare that I am the (check the appropriate box)

Plaintiff

Movant

(filing 42 U.S.C. § 1983)

(filing 28 U.S.C. § 2255 motion)

Petitioner

Other

(writ of habeas corpus

28 U.S.C. §§ 2254 or 2241)

Defendant/Respondent

in this case. I am unable to prepay the fees of this proceeding or give security because of my

poverty. I acknowledge and consent that a portion of any recovery, as directed by the court, shall

be paid to the clerk for reimbursement of all fees incurred by me as a result of being granted leave

to proceed in forma pauperis.

In further support of this application, I answer the following questions:

Are you presently employed?

Yes

If the answer is “yes,” state the amount of your salary or wages per month, and give

the name and address of your employer. (List gross and net salary.)

If the answer is “no,” state the date of last employment and the amount of the salary

or wages per month which you received.

Have you received within the past twelve months any money from any of the following

sources?

Business, profession or other form of self-employment?

Yes

IFP Motion

rev. eff. 7/21/2008 RJH

Application To Proceed In Forma Pauperis - District Of Nevada