Application To Proceed In Forma Pauperis - Us Court

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In the United States Court of Federal Claims
Application to Proceed
In Forma Pauperis
The United States
I, __________________________________________________, request to proceed without being
required to prepay filing fees. I state that because of my poverty, I am unable to pay such fees; that
I believe I am entitled to relief. The nature of my action, or the issues I intend to present are briefly
stated as follows:
In further support of this application, I answer the following questions.
Are you presently employed?
___ Yes ___No
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 both gross and net salary)
If the answer is "no", state the date of last employment and the amount of the salary
and 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 ___No
Rent payments, interest or dividends?
___ Yes ___No
Pensions, annuities or life insurance payments
___ Yes ___No
Gifts or inheritances?
___ Yes ___No
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.


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