Application To Proceed Without Prepayment Of Fees And Affidavit Page 2

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AO 240 Reverse (Rev. 10/03) DC MODIFIED
5.
Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
thing of value?
Yes
No
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. List Minor Children below by initials only and complete attached Reference List for
those Minors.
7.
Additional information (include source descriptions from item 3):
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 in the 6-month period immediately preceding the filing of the complaint/petition/motion or notice of
appeal, the average monthly deposits to the prisoner’s account was $ ____________________, and the average monthly
balance in the prisoner’s account was $ _____________________.
_________________________
______________________________________________________________
SIGNATURE OF AUTHORIZED OFFICER
DATE
K:\XFR\forms\External forms\newforms\IFP appl - AO240.WPD
Page 2 of 3
Form Modified 06/06/05

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