Free Final IFP FORM - Alaska

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UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ALASKA , Plaintiff, vs. , Defendant(s). CASE NO.
(To be supplied by the Court)

APPLICATION TO WAIVE THE FILING FEE (Non-Prisoner)

I, , state under penalty of perjury that I am the plaintiff in this case. I am unable to pay the fees for this proceeding or give security because of my poverty. The type of case I am filing is , and I believe I am entitled to the relief I am requesting. I agree that, if I am granted this application to waive the filing fee in this case, a portion of any recovery, as directed by the Court, will be paid to the Clerk of Court for reimbursement of all fees and costs incurred by me in the case. In support of this application, I answer the following questions under penalty of perjury: 1. 2. Are you currently incarcerated? Marital status: 9 Single a.

9 Yes

9 No (If "Yes" USE PRISONER FORM) 9 Separated

9 Married

9 Divorced

If separated or divorced, do you 9 pay child support or alimony, or 9 receive any child support, alimony or other form of maintenance? If not, check: 9 No If yes to either question, state monthly amount paid: amount received: OR state monthly

b.

Dependants: 9 Spouse

9 Children #

9 Others #

List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their monthly support (and for minor children, use initials only). Name: Name: Name: Name:
PS11 (12/05)

Age: Age: Age: Age: Page 1 of 4
Fee Waiver

3.

Are you presently employed? a.

9 Yes

9 No

If the answer is "Yes," provide the following information: Gross: $ Net: $ salary/wages per 9 month 9 week (chose one)

Employer's name, address & telephone:

Nature of employment: How long employed by present employer: b. If you are not presently employed, provide the following information: Date of last employment: / / (month/day/year)

Former employer's name, address & telephone: Gross: $ Net: $ salary/wages per 9 month 9 week (chose one)

Nature of employment: 4. Is your spouse employed?

9 Yes

9 No

If the answer is "Yes," provide the following information: Gross: $ Net: $ salary/wages per 9 month 9 week (chose one)

Employer's name, address & telephone: Nature of employment: How long employed by present employer: 5. Are you receiving public assistance or unemployment benefits? a.

9 Yes

9 No

I have been on 9 public assistance and/or have received 9 unemployment benefits since: / / (month/day/year).

b.

I am receiving $ of (number).

9 monthly / 9 weekly for myself and my household

PS11 (12/05)

Page 2 of 4

Fee Waiver

6.

In the past 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 (not PFD) Pensions, annuities or life insurance payments Disability or worker's compensation payments Gifts or inheritances Any other sources

9 Yes 9 Yes 9 Yes 9 Yes 9 Yes 9 Yes

9 No 9 No 9 No 9 No 9 No 9 No

If the answer to any of the above is "Yes," describe each source and state the amount and when received, and what you expect you will continue to receive.

7.

List all members of your household, including yourself, who received the Alaska Permanent Fund Dividend within the last twelve months, and the amount(s):

8.

Do you have any cash?

9 Yes

9 No

State the total amount and location(s): 9. Do you have any checking account(s)? a.

9 Yes

9 No

Name(s) and address(es) of bank(s):

10.

b. Present balance(s) in account(s): Do you have any savings/IRA/money market/CDs' separate from checking accounts? 9 Yes 9 No a. Name(s) and address(es) of bank(s):

b. 11.

Present balance(s) in account(s):

Do you own an automobile or other motor vehicle? a. b.
PS11 (12/05)

9 Yes
Model:

9 No

Make:

Year:

What is its current value? $ Page 3 of 4
Fee Waiver

c. d. 12.

Is it financed?

9 Yes

9 No

If so, what is the amount owed? $

Do you own any real estate, stocks, bonds, securities, other financial instruments or other valuable property? 9 Yes 9 No If "Yes," describe the property and state its value:

13.

Do you have any other assets or personal property other than clothing? If "Yes," list the asset(s) and state the value of each asset listed:

9 Yes

9 No

14.

Have you placed any property, assets or money in the name or custody of anyone else in the last two years? 9 Yes 9 No If the answer is "Yes," give the date, describe the property, assets or money, give the name of the person given custody of the item, and the reason for the transfer:

DECLARATION UNDER PENALTY OF PERJURY

I declare under penalty of perjury under the laws of the United States of America that the above information is true and correct.

Executed on: DATE SIGNATURE OF APPLICANT

PS11 (12/05)

Page 4 of 4

Fee Waiver