Roque v. Commissioner of Social Security
ORDER TO AMEND Application to Proceed In Forma Pauperis Within Fourteen (14) Days signed by Magistrate Judge Sheila K. Oberto on 3/21/2017. (Attachments: # 1 IFP Application). (Jessen, A)
OAO 240 (Rev. 9/96)
UNITED STATES DISTRICT COURT
APPLICATION TO PROCEED
WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
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:
Are you currently incarcerated?
(If “No,” go to Part 2)
If “Yes,” state the place of your incarceration
Are you employed at the institution?
Do you receive any payment from the
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
Are you currently employed?
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.
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.
In the past 12 twelve months have you received any money from any of the following sources?
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
If the answer to any of the above is “Yes,” describe, on the following page, each source of money and state
the amount received and what you expect you will continue to receive.
AO 240 Reverse (Rev. 9/96)
Do you have any cash or checking or savings accounts?
If “Yes,” state the total amount.
Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
thing of value?
If “Yes,” describe the property and state its value.
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.
I declare under penalty of perjury that the above information is true and correct.
Signature of Applicant
NOTICE TO PRISONER: A Prisoner seeking to proceed IFP shall submit an affidavit stating all assets. In
addition, a prisoner 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.
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