Application To Proceed In Forma Pauperis - District Of Nevada Page 2

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b.
Rent payments, interest or dividends?
Yes
No
c.
Pensions, annuities or life insurance payments?
Yes
No
d.
Gifts or inheritances?
Yes
No
e.
Any other sources?
Yes
No
If the answer to any of the above is “yes,” describe each source of money and state the
amount received from each during the past twelve months.
3.
Do you own any cash, or do you have money in checking or savings accounts (include any
funds in prison accounts, and any funds on deposit with a bank, saving & loan, etc., outside
the prison) ?
Yes
No
If the answer is “yes,” state the total value and list the location of each account, type of
account, and amount or balance in the account. Do not include your account number(s).
4.
Do you own or have any interest in any real estate, stocks, bonds, notes, trusts, automobiles
or other valuable property (excluding ordinary household furnishings and clothing)?
Yes
No
If the answer is “yes,” describe the property, its location and state its approximate value.
5.
List the persons who are dependent upon you for support, state your relationship to those
persons, and indicate how much you contribute toward their support each month.
6.
Do you receive any income from disability, Social Security or any other pension?
Yes
No
If the answer is “yes,” describe the source and amount received each month.
7.
Have you placed any property, assets or money in the name or custody of anyone else in the
last two years?
Yes
No
If the answer is “yes,” give the date, describe the property, assets or money, give the name
of the person given custody of the item and the reason for the transfer.
IFP Motion
2
rev. eff. 7/21/2008 RJH

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