Application To Proceed In District Court Without Prepaying Fees Or Costs
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AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
U
S
D
C
NITED
TATES
ISTRICT
OURT
for the
__________ District of __________
)
)
Plaintiff/Petitioner
)
Civil Action No.
v.
)
)
Defendant/Respondent
APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS
(Long Form)
Affidavit in Support of the Application
Instructions
I am a plaintiff or petitioner in this case and declare
Complete all questions in this application and then sign it.
that I am unable to pay the costs of these proceedings
Do not leave any blanks: if the answer to a question is “0,”
and that I am entitled to the relief requested. I declare
“none,” or “not applicable (N/A),” write that response. If
under penalty of perjury that the information below is
you need more space to answer a question or to explain your
true and understand that a false statement may result in
answer, attach a separate sheet of paper identified with your
a dismissal of my claims.
name, your case's docket number, and the question number.
Signed:
Date:
1.
For both you and your spouse estimate the average amount of money received from each of the following
sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly,
semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions
for taxes or otherwise.
Income source
Average monthly income
Income amount expected
amount during the past 12
next month
months
You
Spouse
You
Spouse
Employment
$
$
$
$
Self-employment
$
$
$
$
Income from real property
(such as rental income)
$
$
$
$
Interest and dividends
$
$
$
$
Gifts
$
$
$
$
Alimony
$
$
$
$
Child support
$
$
$
$
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