AO 239, Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)

Declaring financial inability to pay proceedings fees requires the execution of the following form. Complete the form and submit it to the court in order to officially request waiving the fees.

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Page 1 of  5AO 239  (Rev. 01/15	
) App	lication to Proceed in District Cou	rt Without Prepaying Fees or Costs (Long Form)	
U	NITED 	S	TATES 	D	ISTRICT 	C	OURT	
for the
__________ District of __________
)
)
)
)
)	
Plaintiff/Petitionerv.	
Civil Action No.	
Defendant/Respondent	
APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS\
 (Long Form) 
Affidavit in Support of the Application
I am a plaintiff or petitioner in this case and declare
that I am unable to pay the costs of these proceedings
and that I am entitled to the relief requested.  I declare
under penalty of perjury that the information below is
true and understand that a false statement may result in
a dismissal of my claims. 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 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 numbe r, and the question number.
Signed: 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. U se gross amounts, that is, amounts before any deductions
for taxes or otherwise.
Income source Average monthly income 
amount during the past 12 months Income amount expected 
next month
You Spouse You Spouse
Employment $$$$
Self-employment $$$$
Income from real property 	
(such as rental income)	$$$$
Interest and dividends $$$$
Gifts $$$$
Alimony $$$$
Child support $$$$

Page 2 of  5AO 239  (Rev. 01/15	
) App	lication to Proceed in District Cou	rt Without Prepaying Fees or Costs (Long Form)	
Retirement 	(such as social security, pensions, annuities,
insurance)	
  $$$$
Disability 
(such as social security, insurance payments)	$$$$
Unemployment payments $$$$
Public-assistance 	
(such as welfare)	$$$$
Other 	
(specify)	: $$$$
Total monthly income: $$$$
2. List your employment history for the past two years, most recent employer first. 	
(Gross monthly pay is before taxes or
other deductions.)	
Employer Address Dates of employment Gross 
monthly pay
$
$
3. List your spouse's employment history for the past two years, most recent employer first. 	
(Gross monthly pay is before
taxes or other deductions.)	
Employer Address Dates of employment Gross 
monthly pay
$
$
$
4. How much cash do you and your spouse have? $ Below, state any money you or your spouse have in  bank accounts or in any other financial institution.
Financial institution Type of account Amount you have Amount your
spouse has	
$	$
$$
$$
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 instituti ons, attach one certified statement of each account.

Page 3 of  5AO 239  (Rev. 01/15	
) App	lication to Proceed in District Cou	rt Without Prepaying Fees or Costs (Long Form)	
5. List the assets, and their values, which you own or
 your spouse owns. Do not list clothing and ordinary
household furnishings.
Assets owned by you or your spouse
Home 	
(Value)	$
Other real estate	
 (Value)	$
Motor vehicle  #1 	
(Value)	$
Make and year:
Model:	
Registration #:	
Motor vehicle  #2 	(Value)	$
Make and year:
Model:	
Registration #:	
Other assets 	(Value)	$
Other assets 	
(Value)	$
6. State every person, business, or organization owi ng 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
$$
$$
$$
7. State the persons who rely on you or your spouse for support.
Name  (or, if under 18, initials only) RelationshipAge

Page 4 of  5AO 239  (Rev. 01/15	
) App	lication to Proceed in District Cou	rt Without Prepaying Fees or Costs (Long Form)	
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, bi weekly, quarterly, semiannually, or annually to show the
monthly rate.
You Your spouse
Rent or home-mortgage payment 	
(including lot rented for mobile home)	
$$
Are real estate taxes included? ’Yes ’No
Is property insurance included? ’Yes ’No
Utilities 	
(electricity, heating fuel,  water, sewer, and telephone)	$$
Home maintenance 	
(repairs and upkeep)	$$
Food $$
Clothing $$
Laundry and dry-cleaning $$
Medical and dental expenses $$
Transportation 	
(not including motor vehicle payments)	$$
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 include d in mortgage payments) (specify):	$$
Installment payments
Motor vehicle: $$
Credit card 	
(name)	: $$
Department store 
(name)	: $$
Other: $$
Alimony, maintenance, and support paid to others $$

Page 5 of  5AO 239  (Rev. 01/15	
) App	lication to Proceed in District Cou	rt Without Prepaying Fees or Costs (Long Form)	
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 inco me or expenses or in your assets or liabilities during the
next 12 months?
’ Yes  ’No If yes, describe on an attached sheet.
10. Have you spent — or will you be spending — any money  for expenses or attorney fees in conjunction with this
lawsuit? ’Yes ’No
If yes, how much? $
11. Provide any other information that will help expl ain why you cannot pay the costs of these proceedings.
12. Identify the city and state of your legal residence. Your daytime phone number:
Your age:   Your years of schooling: