Opinion
2:22-cv-02592-JGB-ADS
06-28-2022
George Anthony Hernandez PRISONER/PLAINTIFF v. Ronald J. Broomfield DEFENDANT(S)
REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
INSTRUCTIONS: This form has two sections. Everyone who submits this form to the Court must complete Section 1, answering all questions and signing to declare, under penalty of perjury, that the answers given are true. Whether Section 2 must be completed depends on the institution where you are confined. If you are incarcerated at:
| PLACE OF INCARCERATION | INSTRUCTIONS |
| California State Prison, Los Angeles County California Men's Colony California Institution for Men California Institution for Women California Rehabilitation Center Chuckwalla Valley State Prison Ironwood State Prison | DO NOT COMPLETE SECTION 2. Leave Section 2 blank. Do NOT have the institution fill out Section 2 and do NOT attach a certified copy of your prison trust account statement. After you submit this application, the Court will direct the California Department of Corrections & Rehabilitation to submit a certified prison trust account statement for you directly to the Court. |
| ANY OTHER INSTITUTION | Have your institution COMPLETE SECTION 2 and return the signed form and a certified copy of your prison trust account statement to you. Send the signed form and the certified trust account statement to the Court with your complaint. |
SECTION 1
1. Where are you currently incarcerated? ________________
2. Are you currently employed in prison? [ ] Yes [ ] No
If the answer is yes, state the number of hours you work per week and the hourly rate of pay:
3. Have you received, within the past twelve months, any money from any of the following sources?
Business, profession or form of self-employment? [ ] Yes [ ]
Rent payments, interest or dividends? [ ] Yes [ ]
Pensions, annuities or life insurance payments? O Yes [ ]
Gifts or inheritances? [ ] Yes [ ]
Any other income (other than listed above)? [ ] Yes [ ]
Loans? [ ] Yes [ ]
If the answer to any of the above is yes, describe such source of money and state the amount received from each source during the past twelve (12) months: ______________________________
4. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison accounts, if applicable.) [ ] Yes [ ] No
If the answer is yes, identify each account and separately state the amount of money held in each account for each of the six (6) months prior to the date of this declaration. _____________
5. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? [ ] Yes [ ] No
If the answer is yes, describe the property and state its approximate value: ____________
6. In what year did you last file an Income Tax Return? __________
Approximately how much income did your last tax return reflect? _____________
7. List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support: ____________
DECLARATION AND AUTHORIZATION
By signing below, I declare under penalty of perjury that:
1. I am the plaintiff in this case;
2. because of my poverty, I am unable to pay the full costs of these proceedings or to give security therefor;
3. I believe that I am entitled to redress; and
4. all answers given above are true, correct, and complete.
I understand that a false statement or answer to any question in this declaration may subject me to penalties for perjury, which is punishable by a term of imprisonment of up to five (5) years and/or a fine of $250,000.
I also understand that, if my request to proceed without prepayment of filing fees is granted, I will be required to pay the full amount of the filing fees for this case in installments over time, regardless of my forma pauperis status or whether I am successful in this case. I therefore authorize the prison officials at this institution to assess, collect, and forward to the Court the full amount of these fees, in monthly payments based on the average of deposits to or balance in my prison trust account, as provided in 28 U.S.C. § 1915.
I also authorize my institution to provide to the Court a certified copy of my prison trust account statement, for activity covering the last six months, if the Court contacts my institution to request this information.
Please indicate the city or county and the state where you are located at the time you sign this declaration, then date and sign below.
City or County ___________ State ___________
I declare under penalty of perjury that the foregoing is true and correct. Executed on:
Date ___________ Prisoner/Plaintiff (Signature) ___________
SECTION 2
DO NOT COMPLETE THIS SECTION IF THE PLAINTIFF IS INCARCERATED AT ONE OF THE FOLLOWING INSTITUTIONS:
California State Prison, Los Angeles County
California Men's Colony
California Institution for Men
California Institution for Women
California Rehabilitation Center
Chuckwalla Valley State Prison
Ironwood State Prison
CERTIFICATE OF AUTHORIZED OFFICER
I hereby certify that __________, the Plaintiff in this case, has credit in the sum of $ __________ on account at __________, the institution where Plaintiff is confined.
I further certify that during the past six months the Plaintiff s average monthly balance was $ __________. I further certify that during the past six months the average of monthly deposits to the Plaintiff s account was $ __________.
A certified copy of the Plaintiff's trust account statement for the last six (6) months is attached.
Date __________ Authorized Officer of Institution (Signature)__________
Authorized Officer of Institution (Print Name) __________