LR Form (Rev. 1/05) UNITED STATES DISTRICT COURT Southern District of West Virginia, Division: Click to select: APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND COSTS v. CASE NUMBER: I, declare that I am the (check appropriate box) G plaintiff/petitioner/movant G appellant G other in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under 28 U.S.C. §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/notice of appeal. In support of this application, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? G Yes (If “Yes,” go to # 3) G No (If “No,” go to # 2) If “Yes,” state the place of your incarceration Are you employed at the institution? Do you receive any payment from the institution? Have the institution fill out the Certificate portion of this application and attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’ transactions. 2. Are you currently employed? Yes (If “Yes,” go to # 2.a) G No (If “No,” go to # 2.b) a. b. 3. If the answer is “Yes,” state the amount of your take-home salary or wages and pay period and give the name and address of your employer. If the answer is “No,” state the date of your last employment, the amount of your take-home salary or wages and pay period and the name and address of your last employer. In the past 12 twelve months have you received any money from any of the following sources? a. b. c. d. e. f. Business, profession or other self-employment Rent payments, interest or dividends Pensions, annuities or life insurance payments Disability or workers compensation payments Gifts or inheritances Any other sources G G G G G G Yes Yes Yes Yes Yes Yes G G G G G G No No No No No No If you answered “Yes” to any portion of question #3, describe each source of money and state the amount received and what you expect you will continue to receive. American LegalNet, Inc. www.USCourtForms.com LR Form 4. (Rev. 1/05) Page 2 G Yes Do you have any cash or checking or savings accounts? G No If “Yes,” state the total amount. 5. 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. 6. List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support. 7. I do hereby stipulate that the recovery, if any, obtained in this action shall be paid to the Clerk of Court, who shall pay therefrom, all unpaid costs taxed against plaintiff and pay the balance to plaintiff and/or his/her attorney, if any. I declare under penalty of perjury that the above information is true and correct. Date Signature of Applicant CERTIFICATE (Incarcerated applicants only) (To be completed by the institution of incarceration) I certify that the applicant named herein has the sum of $________________________ on account to his/her credit at (name of institution) ________________________________________. I further certify that the applicant has the following securities to his/her credit ________________________________________________________________. I further certify that during the past six months the applicant’s average balance was $ _______________, and the average of monthly deposits was $ _________________. _________________ Date ___________________________________________________ Signature of Authorized Officer American LegalNet, Inc. www.USCourtForms.com