Opinion
No. CIV S-10-1897-CMK-P.
July 22, 2010
ORDER
Plaintiff, a prisoner proceeding pro se, brings this civil rights action pursuant to 42 U.S.C. § 1983. Plaintiff has not, however, filed a complete application to proceed in forma pauperis, along with a certified copy of his trust account statement for the six-month period immediately preceding the filing of the complaint, or paid the required filing fee. See 28 U.S.C. §§ 1914(a), 1915(a), (a)(2). Plaintiff will be provided the opportunity to submit either a completed application to proceed in forma pauperis or the appropriate filing fee. Plaintiff is warned that failure to resolve the fee status of this case within the time provided may result in the dismissal of this action for lack of prosecution and failure to comply with court rules and orders. See Local Rule 110.
Accordingly, IT IS HEREBY ORDERED that:
1. Plaintiff shall submit on the form provided by the Clerk of the Court, within 30 days from the date of this order, a complete application for leave to proceed in forma pauperis, with the required certified copy of his trust account statement, or the appropriate filing fee; and
2. The Clerk of the Court is directed to send plaintiff a new form Application to Proceed In Forma Pauperis By a Prisoner.
UNITED STATES DISTRICT COURT EASTERN DISTRICT OF CALIFORNIA APPLICATION TO PROCEED Plaintiff IN FORMA PAUPERIS vs. BY A PRISONER CASE NUMBER: 28 U.S.C. § 1915 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. and 28 U.S.C. § 1915 CERTIFICATE
Defendant(s) 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 , 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. ________________________________________ 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 what you expect you will continue to receive. Please attach an additional sheet if necessary. 4. Do you have cash 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 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 (b)(2). I declare under penalty of perjury that the above information is true and correct. ___________________________ ______________________________________ DATE SIGNATURE OF APPLICANT (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.) ____________________ _____________________________________________________________________ DATE SIGNATURE OF AUTHORIZED OFFICER