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Application to Proceed in District Court Without Prepaying Fees or Costs

Application to Proceed in District Court Without Prepaying Fees or Costs

We are seeking this information to try to get $402 federal filing fee waived as a  courtesy to you, our client. If you want to pay the $402 fee you can do that and not continue with the form

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  • 1
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  • 2
    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 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.
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  • 3
    For both you and your significant other (meaning boyfriend, girlfriend, spouse, or other person you rely on for support), 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, semiannuanlly, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. PLEASE SCROLL FOR ALL THE FIELDS . IF A QUESTION DOEN NOT APPLY PLEASE TYPE NA
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    For both you and your significant other (meaning boyfriend, girlfriend, spouse, or other person you rely on for support), estimate the average amount of money expected from each of the following sources next month. Adjust any amount that is expected to be received weekly, biweekly, quarterly, semiannuanlly, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. PLEASE SCROLL FOR ALL THE FIELDS . IF A QUESTION DOEN NOT APPLY PLEASE TYPE NA
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    Gross monthly pay is before taxes or other deductions
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    Gross monthly pay is before taxes or other deductions
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    **PLEASE SCROLL FOR ALL THE FIELDS .** I
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  • 10
    List the assets, and their values, which you own or your significant other owns. Do not list clothing and ordinary household furnishings.
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    Please list any motor vehicles owned by you or your significant other
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    Please list any other assets and their values that you or your significant other own.
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  • 13
    State every person, business, or organization owing you or your significant other money, and the amount owed
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    Rent or home-mortgage payment (including lot rented for mobile home). Adjust ant payment that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate.
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    • Yes
    • No
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    • Yes
    • No
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  • 16
    Estimate the average monthly expenses of you and your family, Show separatley the amounts paid by your significant other. Adjust ant payment that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. **PLEASE SCROLL FOR ALL THE FIELDS .** IF A QUESTION DOEN NOT APPLY PLEASE TYPE NA
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    Insurance not deducted from wages or included in mortgage payments. **PLEASE SCROLL FOR ALL THE FIELDS .** IF A QUESTION DOEN NOT APPLY PLEASE TYPE NA
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    Taxes not deducted from wages or included in mortgage payments. IF A QUESTION DOES NOT APPLY PLEASE TYPE NA
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  • 19
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  • 20
    Attach a detailed statement
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  • 21
    Please list any other expenses
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  • 22
    Calculated from your previous responses
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  • 23
    Calculated from your previous responses
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  • 24
    Please Select
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    • Yes
    • No
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  • 25

    Have you spent - or will you be spending - any money for expenses or attorney fees in conjunction with this lawsuit?

     

    Yes, Chad Brown Law, P.L.L.C. – EAJA

    25% of past due benefits.

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  • 26
    0/250
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  • 27
    Please Select
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    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
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    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
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    • Dominica
    • Dominican Republic
    • Ecuador
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    • Estonia
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    • French Polynesia
    • Gabon
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    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
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    • Guadeloupe
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    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
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    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
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    • Mexico
    • Micronesia
    • Moldova
    • Monaco
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    • Mozambique
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    • Netherlands
    • Netherlands Antilles
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    • New Zealand
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    • Niger
    • Nigeria
    • Niue
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    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
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    • Palau
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    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
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    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
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    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
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    • Trinidad and Tobago
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    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
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    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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Application to Proceed in District Court Without Prepaying Fees or Costs
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