AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)

UNITED STATES DISTRICT COURT

for the

__________ District of __________

)

)

)

)

)

Plaintiff/Petitioner

v. Civil Action No. 

Defendant/Respondent

APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS

(Short Form)

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.

In support of this application, I answer the following questions under penalty of perjury:

1. If incarcerated. I am being held at: .

If employed there, or have an account in the institution, I have attached to this document a statement certified by the

appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any

institutional account in my name. I am also submitting a similar statement from any other institution where I was

incarcerated during the last six months.

2. If not incarcerated. If I am employed, my employer’s name and address are: 

My gross pay or wages are: $ , and my take-home pay or wages are: $ per

(specify pay period) .

3. Other Income. In the past 12 months, I have received income from the following sources (check all that apply):

(a) Business, profession, or other self-employment ’ Yes ’ No

(b) Rent payments, interest, or dividends ’ Yes ’ No

(c) Pension, annuity, or life insurance payments ’ Yes ’ No

(d) Disability, or worker’s compensation payments ’ Yes ’ No

(e) Gifts, or inheritances ’ Yes ’ No

(f) Any other sources ’ Yes ’ No

If you answered “Yes” to any question above, describe below or on separate pages each source of money and

state the amount that you received and what you expect to receive in the future.

Case 9:20-cv-80729-XXXX Document 1-3 Entered on FLSD Docket 05/01/2020 Page 1 of 2

 Southern District of Florida DEBRA HENRY RONALD DESANTIS, IN HIS OFFICAL CAPACITY 20-80729 N/A

UNEMPLOYED

0.00 0.00 WEEK ✔

✔

✔

✔

✔

✔

APPROXIMATELY $22,000/YEAR FROM EMPLOYMENT PRIOR TO MARCH 17, 2020 (NOW UNEMPLOYED) 

$226.00 ONE TIME PAYMENT FOR UNEMPLOYMENT 

$1200 STIMULUS CHECK

Case 9:20-cv-80729-AHS Document 3 Entered on FLSD Docket 05/01/2020 Page 1 of 2
AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)

4. Amount of money that I have in cash or in a checking or savings account: $ .

5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or

thing of value that I own, including any item of value held in someone else’s name (describe the property and its approximate

value):

6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide

the amount of the monthly expense):

7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship

with each person, and how much I contribute to their support:

8. Any debts or financial obligations (describe the amounts owed and to whom they are payable):

Declaration: I declare under penalty of perjury that the above information is true and understand that a false

statement may result in a dismissal of my claims.

Date:

Applicant’s signature

Printed name

Case 9:20-cv-80729-XXXX Document 1-3 Entered on FLSD Docket 05/01/2020 Page 2 of 2

400.00

$2500.00 2010 CHRYSLER $1000/MONTH RENT 

$220/MONTH AUTO EXPENSES 

$100/MONTH UTILITIES 

$400/MONTH CREDIT CARD (MINIMUM PAYMENT)

N/A

CREDIT CARD(S) $15,000

05/01/2020 Debra Henry DEBRA HENRY Print Save As... Add Attachment Reset

Case 9:20-cv-80729-AHS Document 3 Entered on FLSD Docket 05/01/2020 Page 2 of 2