Application To Proceed In District Court Without Prepaying Fees Or Costs Page 4
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AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
8.
Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your
spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the
monthly rate.
You
Your spouse
Rent or home-mortgage payment
(including lot rented for mobile home)
’ Yes ’ No
Are real estate taxes included?
$
$
Is property insurance included? ’ Yes ’ No
Utilities
$
$
(electricity, heating fuel, water, sewer, and telephone)
Home maintenance
$
$
(repairs and upkeep)
Food
$
$
Clothing
$
$
Laundry and dry-cleaning
$
$
Medical and dental expenses
$
$
Transportation
$
$
(not including motor vehicle payments)
Recreation, entertainment, newspapers, magazines, etc.
$
$
Insurance
(not deducted from wages or included in mortgage payments)
Homeowner's or renter's:
$
$
Life:
$
$
Health:
$
$
Motor vehicle:
$
$
Other:
$
$
Taxes
(not deducted from wages or included in mortgage payments) (specify):
$
$
Installment payments
Motor vehicle:
$
$
Credit card
:
$
$
(name)
Department store
:
$
$
(name)
Other:
$
$
Alimony, maintenance, and support paid to others
$
$
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