Application To Proceed In District Court Without Prepaying Fees Or Costs - United States District Court Page 2

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AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)
4. Amount of money that I have in cash or in a checking or savings account: $
.
5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or
thing of value that I own, including any item of value held in someone else’s name
(describe the property and its approximate
:
value)
6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses
(describe and provide
:
the amount of the monthly expense)
7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship
with each person, and how much I contribute to their support:
8. Any debts or financial obligations
:
(describe the amounts owed and to whom they are payable)
Declaration: I declare under penalty of perjury that the above information is true and understand that a false
statement may result in a dismissal of my claims.
Date:
Applicant’s signature
Printed name
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