Jolly v. Blozen et al

OCR transcription for search; preserved printed pages are authoritative

Case 3:26-cv-00523-BAS-KSC Document3 _ Filed 03/12/26 PagelD.<pagelD> Page
1 of 2

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

UNITED STATES Di COURT
for the

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Plaintiff/Petitioner

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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. fincarcerated. | am being held at: Sie

If employed there, or have an account in the institution, I have attache 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. | am also submitting a similar statement from any other institution where I was
incarcerated during the last six months.

2. If not incarcerated. \f1 am employed, my employer’s name and address are:

My gross pay or wages are: ( gue ,, and my take-home pay or wages are: $ * 45 Ov per

(specify pay period) narnenlg ‘Wig?

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

(a) Business, profession, or other self-employment O Yes uI No
(b) Rent payments, interest, or dividends O Yes #“TNo
(c) Pension, annuity, or life insurance payments 0 Yes BNRo
(d) Disability, or worker’s compensation payments 0 Yes No
(e) Gifts, or inheritances O Yes Go
(f) Any other sources O Yes QA0

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.

AUTHENTICATED
U.S. GOVERNMENT
INFORMATION

GPO

Case 3:26-cv-00523-BAS-KSC Document3 Filed 03/12/26 PagelD.<pagelD> Page
2 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: $ [ 0 °

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

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6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide
the amount of the monthly expense):

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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):

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Declaration: 1 declare under penalty of perjury that the above informatio
statement may result in a dismissal of my claims.

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s true and understand that a false

ted, to signature

Printed name?