UNITED STATES DISTRICT COURT WESTERN DISTRICT OF OKLAHOMA ) ) ) ) ) ) ) ) ) ) ) ) Plaintiff/Petitioner v. CASE NO.: (To be supplied by the Clerk) (Prisoner form) Defendant/Respondent APPLICATION FOR LEAVE TO PROCEED IN FORMA PAUPERIS and supporting affidavit (pursuant to 28 U.S.C. § 1915 and 28 U.S.C. § 1746 for prisoner cases) I hereby apply for leave to: (check one) Commence this action for habeas corpus relief. Commence this action for civil rights relief. without prepayment of fees and costs or giving security therefor. In support of my application, I answer the following questions under penalty of perjury: 1.) 2.) I am the party initiating said action and I believe that I am entitled to relief. The nature of said action is: 3.) 4.) I am unable to prepay the costs of this action or give security therefor because of my poverty. I have no assets or funds which could be used to prepay the fees or costs, except: (Write "none" above if you have nothing; otherwise list your assets.) SR/2013 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 4 5.) I am presently employed: YES NO (a) If the answer is "Yes," state the amount of your salary or wages per month , and give the name and address of your employer: (b) If the answer is "No," state the date of last employment and the amount of the salary and wages per month which you received: 6.) Within the past twelve months I have received money from the following sources: (a) Business, profession, or form of self-employment? YES NO (b) Rent payments, interest, or dividends? YES NO (c) Pensions, annuities, or life insurance payments? YES NO (d) Social security, Veterans Administration, disability pensions, workmen's compensation, or unemployment benefits? YES NO (e) Gifts or inheritances? YES NO (f) 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: 7.) I own cash, including funds in my prison/jail accounts, including any mandatory institutional savings accounts: YES NO If the answer is "Yes," state the total amount of cash owned: 8.) I own real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing). YES NO SR/2013 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 If the answer is "Yes," describe the property and state its approximate value: 9.) The following is additional financial or other information regarding my ability to pay the costs of this action (for example, persons who are dependent on you for support): I hereby authorize the agency having custody of me to collect from my prison/jail account(s) and forward to the Clerk of the United States District Court payments assessed by the Court in accordance with 28 U.S.C. § 1915. I understand that a false statement or answer to any question in this declaration could subject me to penalties of perjury and/or may result in the dismissal of all my claims pursuant to 28 U.S.C. § 1915(e)(2)(a). Executed at (Location) on (Date) (Signature) REQUIRED CERTIFICATION You MUST ATTACH to this application and affidavit a certified copy of your institutional account statement (or institutional equivalent) for the six-month period immediately preceding the filing of this action. You must obtain the certified copy of your institutional account statement (or institutional equivalent) from the appropriate official of each penal institution or jail at which you are or were confined during the six-month period immediately preceding the filing of this action. STATEMENT OF INSTITUTIONAL ACCOUNTS I hereby certify that on , (name of prisoner) had $ in his/her institutional account(s). I further certify that the average monthly deposits to the prisoner's accounts for the six-month period (continued on next page) SR/2013 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 immediately preceding the filing of this action was: $ x 20% = $ . The average monthly balance in the prisoner's account(s) for the six-month period immediately preceding the filing of this action was: $ x 20% = $ . I further certify that the above referenced amounts were calculated pursuant to the prisoner's institutional account(s) a copy of which is attached hereto. (Authorized Prison Official) (Title) SR/2013 American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4