AO 240 (Rev. 6/86) Application to Proceed
United States District Court
DISTRICT OF NEVADA APPLICATION TO PROCEED IN FORMA PAUPERIS, SUPPORTING DOCUMENTATION AND ORDER V.
, declare that I am the (check appropriate box) petitioner/plaintiff
movant (filing 28 U.S.C. 2255 motion)
in the above-entitled proceeding; that, in support of my request to proceed without being required to prepay fees, cost or give security therefor, I state that because of my poverty, I am unable to pay the costs of said proceeding or give security therefor; that I believe I am entitled to relief. The nature of my action, defense, or other proceeding of the issues I intend to present on appeal are briefly stated as follows:
In further support of this application, I answer the following questions. 1. Are you presently employed? Yes 9 No 9 a. If the answer is "yes," state the amount of your salary or wages per month, and give the name and address of your employer. (list both gross and net salary)
If the answer is "no," state the date of last employment and the amount of the salary and wages per month which you received.
Have you received within the past twelve months any money from any of the following sources? Yes 9 No Yes 9 No Yes 9 No Yes 9 No Yes 9 No
a. b. c. d. e.
Business, profession or other form of self-employment Rent payments, interest or dividends? Pensions, annuities or life insurance payments? Gifts or inheritances? Any other sources?
9 9 9 9 9
AO 240 Reverse
If the answer to any of the above is "yes," describe each source of money and state the amount received from each during the past twelve months. 3. Do you own any cash, or do you have money in checking or savings accounts? Yes 9 No 9 (Include any funds in prison accounts.) If the answer is "yes," state the total value of the items owned. Do you own or have any interest in any real estate, stocks, bond, notes, automobiles or other valuable property (excluding ordinary household furnishings and clothing)? Yes 9 No 9 If the answer is "yes," describe the property and state its approximate value. List the persons who are dependent on you for support, state your relationship to those persons, and indicate how much you contribute toward their support.
I declare under penalty of perjury that the foregoing is true and correct. Executed on
(Date) Signature of Applicant
CERTIFICATE (Prisoner Accounts Only) I certify that the applicant named herein has the sum of $ on account to his credit at the institution where his is confined. I further certify that the applicant likewise has the following securities to his credit according to the records of said institution: I further certify that during the last six months the applicant's average balance was $
Authorized Officer of Institution
ORDER OF COURT The application is hereby granted. Let the applicant proceed without prepayment of cost or fees or the necessity of giving security therefor.
The application is hereby denied
United States Judge
United States Judge or Magistrate Judge