Page 1 of 7 AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) /Modified by INSD (07/12) UNITED STATES DISTRICT COURT for the Southern District of Indiana ) ) ) ) ) Plaintiff/Petitioner v. Defendant/Respondent Civil Action No. 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 that I am unable to pay the costs of these proceedings and that I am entitled to the relief requested. I declare under penalty of perjury that the information below is true and understand that a false statement may result in a dismissal of my claims or an adverse ruling on this application. Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is “0,” “none,” or “not applicable (N/A),” write that response. If you need more space to answer a question or to explain your answer, please use the space provided on Page 7 of this form or attach additional sheets, if necessary, identified with your name and the question number. Signed: Date: If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account. 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 Employment Self-employment* Income from real property (such as rental income) Average monthly income amount during the past 12 months You Spouse Income amount expected next month You Spouse $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) /Modified by INSD (07/12) Interest and dividends $ insurance, IRA, 401(k)) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Retirement (such as social security, pensions, annuities, $ $ Child support $ $ Alimony $ $ Gifts, Inheritances, or Trust Funds $ $ $ $ $ $ $ $ Disability (such as social security, disability insurance payments, life insurance payments, or worker’s compensation payments) Unemployment payments Public-assistance (such as welfare) Other (specify): Total monthly income: * If self-employed, please list business assets in the “Business Asset” section of this form. 2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of employment Gross monthly pay $ $ $ 3. List your spouse's employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of employment Gross monthly pay $ $ 4. How much cash do you and your spouse have? $ a. Below, state any money you or your spouse have in bank accounts or in any other financial institution. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 7 AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) /Modified by INSD (07/12) Financial institution Type of account Please specify whose name is on the account or if it is a joint account, please write “joint account” Please list the balance in the account $ $ $ $ $ $ b. Please specify below if you own any stocks, bonds, options, securities, Certificate of Deposits (CDs), or any other financial instruments and list the value of each. Financial instrument Value $ $ $ c. Please indicate if you have a trust fund and, if so, state the value. $_________________ 5. a. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. Assets owned by you or your spouse Home (Value) $ Other real estate (i.e., cottage, vacation home/condo, rental property, land, buildings, etc.) (Please specify and list the value for each.) $ Motor vehicle #1 (Value) $ Make and year: Model: Motor vehicle #2 (Value) $ Make and year: Model: Recreational vehicles (i.e. motorcycle, motor home, camper, snowmobile) (Please specify and list the value of each.) $ American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 7 AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) /Modified by INSD (07/12) Boat (or any other watercraft) (Please specify and list the value for each.) $ Other assets (Please list only items with a value of $500 or more and provide the value for each item.) $ b. If you are self-employed, please list any business assets associated with your business and their value. Business Assets $ Business/Profession/Farm (Value) Business equipment/office equipment (Value) Inventory (Value) $ $ Machinery (Value) $ Livestock (Value) $ Other business assets (Please list only items with a value of $ $500 or more and provide the value for each item.) 6. State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or your spouse money Amount owed to you Amount owed to your spouse $ $ $ State the persons who rely on you or your spouse for support. If the individual is a minor (under the age of 18), please do NOT list the minor’s name; please use ONLY the initials for the minor’s name. Name (or, if under 18, initials only) 8. $ $ 7. $ Relationship/Type of Support Age Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. You Your spouse American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 7 AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) /Modified by INSD (07/12) Rent or Home-Mortgage Payment (including lot rented for mobile home) Are real estate taxes included? Is property insurance included? ’ Yes ’ Yes $ $ ’ No ’ No Utilities (electricity, heating fuel, water, sewer, and telephone) $ Home maintenance (repairs and upkeep) $ Food $ Clothing $ Laundry and dry-cleaning $ Medical and dental expenses $ Transportation (not including motor vehicle payments) $ Recreation, entertainment, newspapers, magazines, etc. $ $ $ $ $ $ $ $ $ Insurance (not deducted from wages or included in mortgage payments) Homeowner's or renter's: $ Life: $ Health: $ Motor vehicle: $ Other: $ Taxes (not deducted from wages or included in mortgage payments) (specify): $ $ $ $ $ $ $ Installment payments Motor vehicle: $ Credit card (name): $ Department store (name): $ Other: $ Alimony, maintenance, and support paid to others $ Regular expenses for operation of business, profession, or farm (attach detailed $ statement) Other (specify): $ Total monthly expenses: $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 7 AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) /Modified by INSD (07/12) 9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? ’ Yes 10. ’ No If yes, describe on an attached sheet. Have you paid — or will you be paying — an attorney any money for services in connection with this case, including the completion of this form? ’ Yes ’No If yes, how much? $ If yes, state the attorney's name, address, and telephone number: 11. Have you paid — or will you be paying — anyone other than an attorney (such as a paralegal or a typist) any money ’ Yes ’ No for services in connection with this case, including the completion of this form? If yes, how much? $ If yes, state the person's name, address, and telephone number: 12. Provide any other information that will help explain why you cannot pay the costs of these proceedings. 13. Identify the city and state of your legal residence. Your daytime phone number: Your age: Your years of schooling: Last four digits of your social-security number: PLEASE CAREFULLY REVIEW THE INFORMATION YOU PROVIDED ABOVE FOR ACCURACY AND COMPLETENESS. PLEASE MAKE SURE YOU HAVE SIGNED AND DATED THIS FORM IN THE SPACES PROVIDED ON PAGE 1 AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) /Modified by INSD (07/12) American LegalNet, Inc. www.FormsWorkFlow.com Page 7 of 7 Please use this page for any additional space you may require. (If you require additional sheets, please attach them to this form and make sure your name is on each additional sheet) Please make sure you list the question number on this sheet (or any additional sheets) to which you are providing additional information. ADDITIONAL INFORMATION: American LegalNet, Inc. www.FormsWorkFlow.com