Application To Proceed Without Prepayment Of Fees And Costs Page 2
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1
2LR Form
(Rev. 1/05)
Page 2
G Yes
G No
4.
Do you have any cash or checking or savings accounts?
If “Yes,” state the total amount.
5.
Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
G Yes
G No
thing of value?
If “Yes,” describe the property and state its value.
6.
List the persons who are dependent on you for support, state your relationship to each person and indicate
how much you contribute to their support.
7.
I do hereby stipulate that the recovery, if any, obtained in this action shall be paid to the Clerk of Court, who
shall pay therefrom, all unpaid costs taxed against plaintiff and pay the balance to plaintiff and/or his/her
attorney, if any.
I declare under penalty of perjury that the above information is true and correct.
Date
Signature of Applicant
CERTIFICATE
(Incarcerated applicants only)
(To be completed by the institution of incarceration)
I certify that the applicant named herein has the sum of $________________________ on account to his/her credit
at (name of institution) ________________________________________. I further certify that the applicant has the
following securities to his/her credit ________________________________________________________________.
I further certify that during the past six months the applicant’s average balance was $ _______________, and the
average of monthly deposits was $ _________________.
_________________
___________________________________________________
Date
Signature of Authorized Officer
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