AO 240 Application to Proceed — Athens (Dkt. 85-1, D.N.H.)
Summary
An Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form) by plaintiff Natasha Athens - Favorite Things in Civil Action No. 1:21-cv-00748-SM against Megan Scholz and BOA, filed January 25, 2022 as Document 85-1. The applicant declares under penalty of perjury an inability to pay the costs of the proceedings. The form reports Social Security income, states that the business is closed after being closed for 6 months January - June 2021 and again since Christmas eve, and lists $ 400.00 in cash or accounts. It is dated 01/24/2022.
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“AO 240 Application to Proceed — Athens (Dkt. 85-1, D.N.H.).”
Original at archive.org. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/exhibit-indigence-no-1-21-cv-00748-dkt-85-1-a5d5dfe930/
, SHA-256 56679e20079aeff49c147c80e110336f1f033b9ab42f086ad6b88fece3873514.Full text
Case 1:21-cv-00748-SM Document 85-1 Filed 01/25/22 Page 1 of 2
AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)
UNITED STATES DISTRICT COURT
for the
New HampshireDistrict
__________ DistrictofCourt
__________
Natasha Athens - Favorite Things )
Plaintiff/Petitioner )
v. ) Civil Action No. 1:21-cv-00748-SM
Megan Scholz, BOA Defendants )
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: $ 841.00 , and my take-home pay or wages are: $ per
(specify pay period) month .
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.
NOW I receive Social Security My business is closed I had a large loss last year due to being closed for
6 months January - June 2021
and now in 2022, I have been closed since Christmas eve
Case 1:21-cv-00748-SM Document 85-1 Filed 01/25/22 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: $ 400.00 .
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):
2008 Suburu and a 1993 Convertible
6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide
the amount of the monthly expense):
many bilss every month rent, gas, oil, lights, computer
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):
Credit cards maxed out into the thousands
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: 01/24/2022 Natasha Athens
Applicant’s signature
Natasha Athens
Printed name
File and source
- File
- 85-att1-exhibit-indigence.pdf
- Size
- 275,685 bytes
- SHA-256
- 56679e20079aeff49c147c80e110336f1f033b9ab42f086ad6b88fece3873514
- Our copy
- 85-att1-exhibit-indigence.pdf
- Original
- archive.org