Opinion
1:21-cv-00693-NONE-EPG
06-14-2021
SLYVAN BATTEN, Plaintiff/Petitioner, v. FRESNO SUPERIOR COURT, Defendants/Respondent.
APPLICATION TO PROCEED FN FORMA PAUPERIS BY A PRISONER
I SLYVAN BATTEN declare that I am the plaintiff in the above-entitled proceeding; that, in support of my request to proceed without prepayment of fees under 28 U.S.C. section 1915,1 declare that I am unable to pay the fees for these proceedings or give security therefor and that I am entitled to the relief sought in the complaint.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? ___√__Yes ___No (If "no" DO NOT USE THIS FORM) State the place of your incarceration.
2. Are you currently employed (includes prison employment)? ___Yes ___No
a. If the answer is "yes" state the amount of your pay. N/A
b. 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.
3. Have you received any money from the following sources over the last twelve months?
a. Business, profession, or other self-employment: ___Yes __√_No
b. Rent Payments, interest or dividends: ___Yes __√_No
c. Pensions, annuities or life insurance payments: ___Yes __√_No
d. Disability or workers compensation payments: ___Yes __√_No
e. Gifts or inheritances: ___Yes __√_No
f. Any other sources: ___Yes __√_No
If the answer to any of the above is "yes," describe by that item each source of money, state the amount received, as well as what you expect you will continue to receive (attach an additional sheet if necessary). .
4. Do you have cash (includes balance of checking or savings accounts)? ___Yes __√_No
If "yes" state the total amount:
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other valuable property? ___Yes __√_No
If "yes" describe the property and state its value: :
6. Do you have any other assets? ___Yes __√_No
If "yes," list the asset(s) and state the value of each asset listed:
7. List all persons dependent on you for support, stating your relationship to each person listed and how much you contribute to their support.
This form must be dated and signed below for the court to consider your application.
I hereby authorize the agency having custody of me to collect from my trust account and forward to the Clerk of the United States District Court payments in accordance with 28 U.S.C. § 1915(b)(2).
CERTIFICATE
(To be completed by the institution of incarceration)
I certify that the applicant named herein has the sum of $___on account to his/her credit at _____(name of institution). I further certify that during the past six months the applicant's average monthly balance was $___. I further certify that during the past six months the average monthly deposits to the applicants account was $_____.
(Please attach a certified copy of the applicant's trust account statement showing transactions for the past six months.)