United States District Court
DISTRICT OF NEVADA
APPLICATION TO PROCEED
IN FORMA PAUPERIS
, declare that I am the (check the appropriate box)
(filing 42 U.S.C. § 1983)
(filing 28 U.S.C. § 2255 motion)
(writ of habeas corpus
28 U.S.C. §§ 2254 or 2241)
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?
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
Business, profession or other form of self-employment?
rev. eff. 7/21/2008 RJH