Application To Proceed In District Court Without Prepaying Fees Or Costs Page 2
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AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
Retirement
(such as social security, pensions, annuities,
$
$
$
$
insurance)
Disability
(such as social security, insurance payments)
$
$
$
$
Unemployment payments
$
$
$
$
Public-assistance
(such as welfare)
$
$
$
$
Other
:
(specify)
$
$
$
$
$
$
$
$
0.00
0.00
0.00
0.00
Total monthly income:
2.
List your employment history for the past two years, most recent employer first.
(Gross monthly pay is before taxes or
other deductions.)
Employer
Address
Dates of employment
Gross
monthly pay
$
$
3.
List your spouse's employment history for the past two years, most recent employer first.
(Gross monthly pay is before
taxes or other deductions.)
Employer
Address
Dates of employment
Gross
monthly pay
$
$
$
4.
How much cash do you and your spouse have? $
Below, state any money you or your spouse have in bank accounts or in any other financial institution.
Financial institution
Type of account
Amount you have
Amount your
spouse has
$
$
$
$
$
$
If you are a prisoner, you 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.
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