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OAO 240 (Rev. 10/03) DC MODIFIED

UNITED STATES DISTRICT COURT
District of Minnesota
APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT

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Plaintiff V.

CASE NUMBER:

Defendant
I, petitioner/plaintiff/movant other declare that I am the (check appropriate box)

in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under 28 USC §1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in the complaint/petition/motion. In support of this application, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? If "Yes," state the place of your incarceration Are you employed at the institution? Do you receive any payment from the institution? Yes No (If "No," go to Part 2)

Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months' transactions. 2. Are you currently employed? a. Yes No

If the answer is "Yes," state the amount of your take-home salary or wages and pay period and give the name and address of your employer.

b.

If the answer is "No," state the date of your last employment, the amount of your take-home salary or wages and pay period and the name and address of your last employer.

3.

In the past 12 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 Pensions, annuities or life insurance payments Disability or workers compensation payments Gifts or inheritances 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, in item 7 on the following page, each source of money and state the amount received and what you expect you will continue to receive. 4. Do you have any cash or checking or savings accounts? If "Yes," state the total amount(s).
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Yes

No
Form Modified 06/06/05

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AO 240 Reverse (Rev. 10/03) DC MODIFIED

5.

Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other thing of value? Yes No If "Yes," describe the property and state its value.

6.

List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support. List Minor Children below by initials only and complete attached Reference List for those Minors.

7.

Additional information (include source descriptions from item 3):

I,

declare, under penalty of perjury, that the above information is true and correct.

Date

Signature of Applicant

CERTIFICATE
(Incarcerated applicants only) (To be completed by the institution of incarceration) I, ___________________________, certify that the applicant named herein has the sum of $_________________ on account to his/her credit at (name of institution) _________________________________________. I further certify that the applicant has the following securities to his/her credit: ______________________________________________ _________________________________________________________________________________________. I further certify that in the 6-month period immediately preceding the filing of the complaint/petition/motion or notice of appeal, the average monthly deposits to the prisoner's account was $ ____________________, and the average monthly balance in the prisoner's account was $ _____________________. _________________________ DATE ______________________________________________________________ SIGNATURE OF AUTHORIZED OFFICER

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Form Modified 06/06/05

UNITED STATES DISTRICT COURT
DISTRICT OF MINNESOTA

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REFERENCE LIST FILED UNDER SEAL _______________________________ Plaintiff, vs. Civil Action Number ____cv________/____ ________________________________ ________________________________ ________________________________ ________________________________ Defendant(s) - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

MINOR CHILDREN'S INITIALS

MINOR CHILDREN'S NAME

DATED: ______________ Signature of Plaintiff

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Form Modified 06/06/05