Application To Proceed In Forma Pauperis - United States Court Of Federal Claims
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2In the United States Court of Federal Claims
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__________________________________
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__________________________________
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Plaintiff(s),
Case No. _______________________
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v.
Judge _______________________
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THE UNITED STATES,
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Defendant.
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Application to Proceed In Forma Pauperis
I,____________________________________, declare that the following is true and correct; that I am
the plaintiff in the above entitled case; that in support of my application to proceed without being
required to prepay fees, costs, or give security thereof, I state that because of my poverty, I am
unable to pay the costs of said proceedings or to give security thereof, and that I am entitled to relief
pursuant to 28 U.S.C. § 1915.
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1. Are you incarcerated?
Yes
No
(If the answer is no, go to question 2.)
I am being held at: ________________________________________________________________
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Do you receive any payment from this institution?
Yes
No
Monthly amount: ________________________________________
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I have attached a “Prisoner Authorization form,” see 28 U.S.C. §1915(h), directing the
Facility where I am incarcerated to deduct the filing fee from my account in installments and
to send to the court certified copies of my account statements for the past six (6) months. See
28 U.S.C. § 1915(a)(2), (b).
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2. Are you currently employed?
Yes
No
a. If the answer is yes, give the name and address of your employer and state the amount of
your salary or wages per month (both gross and net).
b. If the answer is no, state the date of last employment and the amount of your salary or
wages per month (both gross and net).
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