Application To Proceed Without Prepayment Of Fees And Costs
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1
2LR Form
(Rev. 1/05)
U
S
D
C
NITED
TATES
ISTRICT
OURT
Click to select:
Southern
District of
West Virginia, Division:
APPLICATION TO PROCEED
WITHOUT PREPAYMENT OF
FEES AND COSTS
v.
CASE NUMBER:
,
declare that I am the (check appropriate box)
I
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:
G Yes
G No
1.
Are you currently incarcerated?
(If “Yes,” go to # 3)
(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.
G No
2.
Are you currently employed?
Yes
(If “Yes,” go to # 2.a)
(If “No,” go to # 2.b)
a.
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.
b.
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.
3.
In the past 12 twelve months have you received any money from any of the following sources?
G
G No
a.
Business, profession or other self-employment
Yes
G
G No
b.
Rent payments, interest or dividends
Yes
G
G No
c.
Pensions, annuities or life insurance payments
Yes
G
G No
d.
Disability or workers compensation payments
Yes
G
G No
e.
Gifts or inheritances
Yes
G
G No
f.
Any other sources
Yes
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.
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