UNITED STATES DISTRICT COURT WESTERN DISTRICT OF OKLAHOMA ) ) ) ) ) ) ) ) ) ) ) ) Print Form Plaintiff v. CASE NO.: (To be supplied by the Clerk) (Non-Prisoner form) Defendant APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS I am a plaintiff in this case and declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief requested. In support of this application, I answer the following questions under penalty of perjury: 1. If I am employed, my employer's name and address are: My gross pay or wages are: $ (specify pay period) . , and my take-home pay or wages are: $ per 2. Other Income. In the past 12 months, I have received income from the following sources (check all that apply) (a) Business, profession, or other self-employment (b) Rent payments, interest, or dividends (c) Pension, annuity, or life insurance payments (d) Disability or worker's compensation payments (e) Gifts or inheritances (f) Any other sources YES YES YES YES YES YES NO NO NO NO NO NO If you answered "Yes" to any questions above, describe below or on separate pages each source of money and state the amount that you received and what you expect to receive in the future. SR-11-2014 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 3. Amount of money that I have in cash or in a checking or savings account: $ . (describe the property and its approximate value) 4. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or thing of value that I own, including any item of value held in someone else's name (describe the amount of the monthly expense) 5. Any housing, transportation, utilities, loan payments, or other regular monthly expenses 6. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship with each person, and how much I contribute to their support: 7. Any debts or financial obligations (describe the amounts owed and to whom they are payable) 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). Date: (Applicant's signature) (Printed name) SR-11-2014 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com