Opinion
ORDER
ALLISON CLAIRE, Magistrate Judge.
Plaintiff, a state prisoner proceeding pro se, has filed a civil rights action pursuant to 42 U.S.C. § 1983 together with a request for leave to proceed in forma pauperis pursuant to 28 U.S.C. § 1915. However, the certificate portion of the in forma pauperis application has not been filled out and signed by an authorized prison official. See 28 U.S.C. § 1915(a)(2). Plaintiff will be provided another opportunity to submit a fully completed application to proceed in forma pauperis.
In accordance with the above, IT IS HEREBY ORDERED that:
1. Plaintiff's motion to proceed in forma pauperis (ECF No. 6) is denied without prejudice;
2. The Clerk of the Court shall provide plaintiff with another copy of the in forma pauperis application used by this court; and
3. Plaintiff shall submit, within thirty days from the date of this order, a fully completed in forma pauperis application. Plaintiff's failure to comply with this order will result in a recommendation that this action be dismissed without prejudice.
I ________________________________________________, 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. § 1915, I 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)
If "Yes" state the place of your incarceration, ____________________________________
Have the institution Fill out the Certificate portion of this application and attach a certified copy of your prison trust account statement showing transactions for the past six months.
2. Are you currently employed? [] Yes [] 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. In the past twelve months have you received any money from any of the following sources?
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 and state the amount received and what you expect you will continue to receive. Please attach an additional sheet if necessary.
4. Do you have cash or 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 the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support.
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).
I declare under penalty of perjury that the above information is true and correct.
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 of monthly deposits to the applicant's account was $________.
(Please attach a certified copy of the applicant's trust account statement showing transactions for the past six months.)