OAO 240 (Rev. 10/03)
UNITED STATES DISTRICT COURT
APPLICATION TO PROCEED
WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
declare that I am the (check appropriate box)
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC §1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated?
(If “No,” go to Part 2)
If “Yes,” state the place of your incarceration
Are you employed at the institution?
Do you receive any payment from the institution?
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
2. Are you currently employed?
If the answer is “Yes,” state the amount of your take-home salary or wages and pay period and give the
name and address of your employer.
If the answer is “No,” state the date of your last employment, the amount of your take-home salary or wages
and pay period and the name and address of your last employer.
In the past 12 twelve months have you received any money from any of the following sources?
Business, profession or other self-employment
b. Rent payments, interest or dividends
Pensions, annuities or life insurance payments
d. Disability or workers compensation payments
e. Gifts or inheritances
Any other sources
If the answer to any of the above is “Yes,” describe, on the following page, each source of money and state the
amount received and what you expect you will continue to receive.
AO 240 Reverse (Rev. 10/03)
Do you have any cash or checking or savings accounts?
If “Yes,” state the total amount.
Do you own any real estate, stocks, bonds, secu