UNITED STATES DISTRICT COURT , ) ) Plaintiff, ) ) Civil Case No. v. ) ) , ) ) Defendant(s). ) APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Short Form) 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. In support of this application, I answer the following questions under penalty of perjury: 1.If incarcerated. I am being held at:. If employed there, or have an account in the institution, I have attached to this document a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any institutional account in my name. I am also submitting a similar statement from any other institution where I was incarcerated during the last six months. 2.If not incarcerated. If I am employed, my employer222s name and address are: My gross pay or wages are: $ , and my take-home pay or wages are: $ per (specify pay period) . 3.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 Yes No (b) Rent payments, interest, or dividends Yes No (c) Pension, annuity, or life insurance payments Yes No (d) Disability or worker222s compensation payments Yes No (e) Gifts or inheritances Yes No (f) Any other sources Yes No If you answered 223Yes224 to any question 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. American LegalNet, Inc. www.FormsWorkFlow.com 4. Amount of money that I have in cash or in a checking or savings account: $ . 5. 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 else222s name (describe the property and its approximate value): 6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide the amount of the monthly expense): 7. 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: 8. Any debts or financial obligations (describe the amounts owed and to whom they are payable): Declaration: I declare under penalty of perjury that the above information is true and understand that a false statement may result in a dismissal of my claims. Applicant222s Signature Printed Name Date American LegalNet, Inc. www.FormsWorkFlow.com