Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)

Federal judicial district where the case is filed. The PDF dropdown lists all 94 districts; the wizard matches typed entries to the dropdown's exact strings. Wrong district = case dismissed for lack of venue.

• Filers type the state name only (e.g., 'California'). The form needs a specific district like 'Eastern District of California'.
• Filers pick the wrong district (e.g., they live in San Diego but type 'Northern District of California' which covers San Francisco). Use 28 U.S.C. 1391 to pick the venue: where the defendant resides, where the events happened, or where any defendant is subject to personal jurisdiction.

The party bringing the case (you). Must match the caption of your complaint exactly.

The party being sued. List the first defendant; if multiple, write 'et al.' after the name (per FRCP caption convention).

Civil action number. Blank for new cases (clerk assigns at filing). For pending cases (mid-case IFP filing), copy from the docket.

Item 1 routing. AO 240 (Short Form) is for non-incarcerated filers. Incarcerated filers should use AO 239 (Long Form) and attach the 6-month inmate trust account statement.

Facility name and address where the incarcerated filer is being held. Required only if is_incarcerated = yes.

Item 2 employer info. Acceptable: 'Unemployed', 'Self-employed', 'Not employed', or a real employer's name and address.

• Filers leave it blank because they are unemployed. Type 'Unemployed' explicitly so the answer is on the form.

Pre-tax pay per the pay period below. Blank or '0' if unemployed.

After-tax pay per the pay period below.

Weekly, bi-weekly, monthly, annual, or no pay. The judge multiplies by the period to estimate annual income.

Item 3.a checkbox. Yes if you have any self-employment income in the past 12 months.

Item 3.b checkbox. Yes if you have rent, interest, or dividend income.

Item 3.c checkbox. Yes if you receive pension, annuity, or life insurance payments.

Item 3.d checkbox. Yes if you receive disability or worker's comp payments. INCLUDES SSDI, VA disability, and state worker's comp.

Item 3.e checkbox. Yes if you receive gifts or inheritances. Include money from family, even if irregular.

Item 3.f checkbox. Catch-all for any other income source not covered above.

Free-text description of every 'Yes' answer above. Required when any of items 3.a-3.f are Yes.

Total cash + checking + savings. The judge uses this with monthly expenses to assess whether the $405 fee is feasible. Lying here is perjury under 28 U.S.C. 1746; the court can verify with bank records.

Property of value: cars, real estate, stocks, bonds, jewelry, art, items held in another's name on your behalf. Skip ordinary household items. 'None' if no significant property.

Itemized monthly expenses: rent, utilities, transportation, loan payments. The judge compares against income.

Dependents you financially support. Use initials for children under 18 (per the form's privacy norm; FRCP 5.2 also requires redacted minor names in pleadings).

Debts and financial obligations: credit cards, medical bills, student loans, child support arrears, court fines.

Wet-ink signature under penalty of perjury (28 U.S.C. 1746). Federal courts require a real signature on paper filings. Some districts accept '/s/ John Smith' on e-filed PDFs.

Date of signature. Sign and date the same day you file.

Printed name on the line below the signature.