UNITED STATES DISTRICT COURT District of Kansas Plaintiff/Petitioner APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT BY A PRISONER Defendant/Respondent CASE NUMBER I, , declare that I am the (check appropriate box) G petitioner/plaintiff/movant G other 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? G Yes GNo (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’ transactions. 2. Do you have any cash or checking or savings accounts? G Yes G No If “Yes,” state the total amount. American LegalNet, Inc. www.USCourtForms.com 3. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other thing of value? G Yes G No If “Yes,” describe the property and state its value. I declare under penalty of perjury that the above information is true and correct. Signed at: (Location) (Date) (Signature) (Inmate Number) NOTICE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, 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. American LegalNet, Inc. www.USCourtForms.com