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Bolds v. Leuvanos

United States District Court, Eastern District of California
Nov 19, 2021
1:21-cv-01668-SAB (E.D. Cal. Nov. 19, 2021)

Opinion

1:21-cv-01668-SAB

11-19-2021

Bolds Plaintiff/Petitioner, v. Leuvanos Defendants/Respondent.


APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER

I, Jon-Erik Roosevelt Boloo Jr., 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, 1Ideclare 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? X Yes ___ No. (If "no" DO NOT USE THIS FORM) State the place of your incarceration. ___.
2. Are you currently employed (includes prison employment)? ___ Yes X No
a. If the answer is "yes" state the amount of your pay ___.
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 X No
b. Rent payments, interest or dividends: ___ Yes X No
c. Pensions, annuities or life insurance payments: ___ Yes X No
d. Disability or workers compensation payments: ___ Yes X No
e. Gifts or inheritances: ___ Yes X No
f. Any other sources: ___ Yes X 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 X 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 X No
If "yes" describe the property and state its value: ___
6. Do you have any other assets? ___ Yes X 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).


Summaries of

Bolds v. Leuvanos

United States District Court, Eastern District of California
Nov 19, 2021
1:21-cv-01668-SAB (E.D. Cal. Nov. 19, 2021)
Case details for

Bolds v. Leuvanos

Case Details

Full title:Bolds Plaintiff/Petitioner, v. Leuvanos Defendants/Respondent.

Court:United States District Court, Eastern District of California

Date published: Nov 19, 2021

Citations

1:21-cv-01668-SAB (E.D. Cal. Nov. 19, 2021)