United States District Court District of Rhode Island APPLICATIONTOPROCEEDPlaintiffWITHOUTPREPAYMENTOFFEESANDAFFIDAVITv.CASENUMBER:DefendantI,,declarethatIamthe(checkappropriatebox)Petitioner/Plaintiff/Movantotherintheaboveentitledproceeding;thatinsupportofmyrequesttoproceedwithoutprepaymentoffeesorcostsunder28U.S.C.2471915,IdeclarethatIamunabletopaythecostsoftheseproceedingsandthatIamentitledtothereliefsoughtinthecomplaint/petition/motion.Insupportofthisapplication,Ianswerthefollowingquestionsunderpenaltyofperjury:1. Areyoucurrentlyincarcerated?YesNo(If223No,224gotopart2)If223Yes,224statetheplaceofyourincarceration:Areyouemployedattheinstitution?YesNoDoyoureceiveanypaymentfromtheinstitution?YesNoIftheansweris223Yes,224attachacertifiedledgersheetfromtheinstitution(s)ofyourincarcerationshowingatleastthepast(6)sixmonths222transactions.2. Areyoucurrentlyemployed?YesNoa) Iftheansweris223Yes,224statetheamountofyourtakehomesalaryorwagesandpayperiodandgivethenameandaddressofyouremployer:b) Iftheansweris223No,224statethedateofyourlastemployment,theamountofyourtakehomesalaryorwagesandpayperiod,andthenameandaddressofyourlastemployer.Also,explainhowyouhavebeensupportingyourself: American LegalNet, Inc. www.FormsWorkFlow.com 3. Haveyoureceivedinthepast(12)twelvemonths,ordoyouanticipatereceivinginthefuture,anymoneyfromanyofthefollowingsources?a) Business,professionorotherselfemploymentYesNob) Rentpayments,interestordividendsYesNoc) Pensions,annuitiesorlifeinsurancepaymentsYesNod) DisabilityorworkerscompensationpaymentsYesNoe) GiftsorinheritancesYesNof) AnyotherpersonsorsourcesYesNoIftheanswertoanyoftheaboveis223Yes,224describeeachsourceofmoneyandstatetheamountreceivedandwhatyouexpectyouwillcontinuetoreceive:4. Listanyonewhohelpssupportyouorsharessupportinanywayanddescribethetypeandamountofsuchsupportforthelasttwelvemonths.Ifnoone,write223NOONE.2245. Doyouhaveanycashorcheckingorsavingsaccounts?YesNoIf223Yes,224statethetotalamount:6. Doyouownanyrealestate,stocks,bonds,securities,otherfinancialinstruments,automobilesoranyotherthingofvalue?YesNoIf223Yes,224describethepropertyandstateitsvalue:7. Doyouhaveanyhousing,transportation,utilities,orloanpayments,orotherregularmonthlyexpenses?YesNoIf223Yes,224describeandprovidetheamountofthemonthlyexpense: American LegalNet, Inc. www.FormsWorkFlow.com 8. Doyouhaveanydebsorfinancialobligations?YesNoIf223Yes,224describetheamountsowedandtowhomtheyarepayable:9. Haveyoutransferredanyassetswithinthelast12monthspriortofilingthisapplication?YesNoIf223Yes,224describetheassetandstateitsvalue:10. Listthepersonswhoaredependentonyouforsupport,stateyourrelationshiptoeachpersonandindicatehowmuchyouactuallycontributetotheirsupport.Pleaselistminorchildrenbyinitialsonly.Ideclareunderpenaltyofperjurythattheaboveinformationistrueandcorrect.DateSignatureofApplicantNOTICETOPRISONER:Aprisonerseekingtoproceedwithoutprepaymentoffeesshallsubmitanaffidavitstatingallassets.Inaddition,aprisonermustattachastatementcertifiedbytheappropriateinstitutionalofficershowingallreceipts,expenditures,andbalancesduringthelastsixmonthsinyourinstitutionalaccounts.Ifyouhavemultipleaccounts,perhapsbecauseyouhavebeeninmultipleinstitutions,attachonecertifiedstatementofeachaccount. FORCOURTPURPOSESONLY:APPROVEDDENIEDU.S.MAGISTRATEJUDGEDATE American LegalNet, Inc. www.FormsWorkFlow.com