Form Ao 239 - Application To Proceed In District Court Without Prepaying Fees Or Costs Page 5
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AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
Regular expenses for operation of business, profession, or farm
(attach detailed
$
$
statement)
Other
:
$
$
(specify)
$
$
0.00
0.00
Total monthly expenses:
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
’ No
If yes, describe on an attached sheet.
10.
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
any money
(such as a paralegal or a typist)
’ 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:
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