Free Application to Proceed without Payment   - West Virginia

UNITED STATES DISTRICT COURT Northern District of West Virginia
_________________________ Plaintiff, V. CASE NUMBER: _________________________ Defendant. APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT

YOU MUST COMPLETE THIS FORM FOR YOU, YOUR SPOUSE AND ALL PERSONS OVER 18 LIVING IN THE RESIDENCE WHERE YOU LIVE
Affidavit in Support of Motion I swear or affirm under penalty of perjury that, because of my poverty, I cannot prepay the docket fees of my action or post a bond for them. I believe I am entitled to redress. I swear or affirm under penalty of perjury under United States laws that my answers on this form are true and correct (28 U.S.C. § 1746; 18 U.S.C. § 1621.) Signed: ____________________________ Instructions Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is "0," "none," or "not applicable (N/A)," write in that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name, your case's docket number, and the question number.

Date: _____________________

1. For both you and your spouse estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amount, that is amounts before any deductions for taxes or otherwise. Income Source Average Monthly Amount during the past 12 months You Employment Self-Employment Income from real property (such as rental income) Interest and dividends Gifts $ $ Spouse $ $ Other Adult* $ $ Amount expected next month

You $ $

Spouse $ $

Other Adult* $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

* Other adult living where you reside

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Alimony Child Support

$ $

$ $

$ $

$ $

$ $

$ $

Retirement (social security, pensions, annuities, insurance, etc.) $ Disability (social security, insurance payments, etc.) Unemployment payments Public-Assistance (such as welfare) Other (specify):

$

$

$

$

$

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

Total monthly income: $

2. List your employment history with most recent employer first (Gross monthly pay is before taxes or other deductions). Employer Address Dates of Employment Gross Monthly Pay

_______________ _______________ _______________

_______________ _______________ _______________

_______________ _______________ _______________

_______________ _______________ _______________

3. List your spouse's employment history with most recent employer first (Gross monthly pay is before taxes or other deductions).

_______________ _______________ _______________

_______________ _______________ _______________

_______________ _______________ _______________

_______________ _______________ _______________

4. How much cash do you and your spouses have? $ Below, state any money you or your spouse have in bank accounts or in any other financial institution

Financial Institution

Type of Account

Amount you have

Amount your spouse has $ $ $

Amount other adult has* $ $ $

$ $ $

If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account.

* Other adult living where you reside

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5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. Home (Value) Other real estate (Value) Motor vehicle #1 Make & year: (Value)

Model:

Registration #:

Motor vehicle #2 Make & year: Model: Registration #:

(Value)

Other assets

(Value)

Other assets

(Value)

6. State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or your spouse money Amount owed to you Amount owed to your spouse money

7. State the persons who rely on you or your spouse for support. Initials Relationship

Age

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, semi-annually or annually to show the monthly rate. You Rent or home mortgage payment (include lot rented for mobile home) Are real estate taxed included? ~ Yes Is property insurance included? ~ Yes $ ~ No ~ No $ Your Spouse Other adult* $

Utilities (electricity, heating fuel, water, sewer, and telephone) $ Home maintenance (repairs and upkeep) Food Clothing Laundry and dry cleaning * Other adult living where you reside $ $ $ $

$ $ $ $ $

$ $ $ $ $

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Medical and dental expenses Transportation (not including motor vehicle payment) 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 other Regular expenses for operation of business, profession, or farm (attach detailed statement Other (specify):___________________ Total monthly expenses:

$

$

$

$ $ $

$ $ $

$ $ $

9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? ~ Yes ~ No If yes, describe on an attached sheet

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10. Have you paid-or will you be paying- an attorney any money for services in connection with this case including the completion of this form? ~ Yes ~ No If yes, how much? $_________________________ If yes, state the attorney's name, address, and telephone number:

11. Have you paid-or will you be paying-anyone other than an attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion of this form? ~ Yes ~ No If yes, how much? $___________________________________ If yes, state the person's name, address, and telephone number:

12. Provide any other information that will help explain why you cannot pay the docket fees for your appeal.

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