Free In Forma Pauperis (IFP) Application - Washington

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF WASHINGTON Case Number:

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Plaintiff/Petitioner vs.

APPLICATION TO PROCEED IN FORMA PAUPERIS, SUPPORTING DOCUMENTATION AND ORDER

Defendant(s)/Respondent(s) I, (print your name) declare I am the plaintiff/petitioner in the above entitled proceeding; that, in support of my request to proceed without being required to prepay fees, costs 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 or the issues I intend to present are briefly stated as follows: In support of this application, I answer all of the following questions: 1. Are you presently employed? Yes If 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):

No

If No, state the date of last employment and the amount of the salary and wages per month which you received:

2. In the past twelve months, have you received any money from any of the following sources? a. Business, profession or other self-employment b. Rent payments, interest or dividends c. Pensions, annuities or life insurance payments d. Disability or workers compensation payments e. Gifts or inheritances f. Any other sources Yes Yes Yes Yes Yes Yes No No No No No No

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: Business, profession or other self-employment Rent payments, interest or dividends

Pensions, annuities or life insurance payments Disability or workers compensation payments Gifts or inheritances Any other sources

3. Do you own any cash, or do you have money in checking or savings accounts? Yes No 4. Do you own or have any interest in any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes No 5. Are any persons dependent upon you for support? If Yes, state your relationship to those persons, and indicate how much you contribute toward their support: If Yes, describe the property and state its approximate value: If Yes, state the total value of each item (include prison account funds)

Yes No

I declare under penalty of perjury that the foregoing is true and correct. Executed on: ___________________________________________________ Signature of Applicant Certification (For Prisoner Applicants Only) Have the institution fill out the Certification portion of this application and attach a certified copy of your prison trust account statement showing transactions for the past six months. I certify that the applicant named herein has the sum of $_______________ on account to his/her credit at (Name of Institution) ___________________ Dated: Signature of Financial Officer ________________________________________________________ Order of Court The application is hereby denied. The application is hereby granted. Let the applicant proceed without prepayment of costs or fees or the necessity of giving security therefor. ___________________________ United States Judge or Magistrate Judge _________________ Date

___________________________ United States Judge or Magistrate Judge

_________________ Date