Opinion
No. CIV S-08-2115 GGH P.
October 8, 2008
ORDER
Plaintiff, a 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 request which must be completed by plaintiff's institution of incarceration has not been filled out. Also, plaintiff has not filed a certified copy of his trust account statement for the six month period immediately preceding the filing of the complaint.See 28 U.S.C. § 1915(a)(2). Plaintiff will be provided the opportunity to submit a completed in forma pauperis application and a certified copy in support of his application.
In accordance with the above, IT IS HEREBY ORDERED that:
1. Plaintiff shall submit, within thirty days from the date of this order, a completed affidavit in support of his request to proceed in forma pauperis on the form provided by the Clerk of Court;
2. The Clerk of the Court is directed to send plaintiff a new Application to Proceed In Forma Pauperis By a Prisoner; and
3. Plaintiff shall submit, within thirty days from the date of this order, a certified copy of his trust account statement for the six month period immediately preceding the filing of the complaint. Plaintiff's failure to comply with this order will result in a recommendation that this action be dismissed without prejudice. APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT 28 USC § 1915
UNITED STATES DISTRICT COURT Eastern District of California Plaintiff, v. CASE NUMBER: Defendant. I, ____________________________________, declare that I am the (check appropriate box) petitioner/plaintiff/movant other in the above-entitled proceeding: that in support of my request to proceed without prepayment of fees or costs under I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in the complaint/petition/motion. In support of this application, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? Yes No (If "No," go to Part 2) If "Yes," state the place of your incarceration __________________________________________________________ Are you employed at the institution? ______ Do you receive any payment from the institution? _________ Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months' transactions. 2. Are you currently employed? Yes No a. If the answer is "Yes," state the amount of your take-home salary or wages and pay period and give the name and address of your employer. 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 12 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, on the following page, each source of money and state the amount received and what you expect you will continue to receive. 4. Do you have any 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 any other thing of value? Yes No If "Yes," describe the property and state its value. 6. 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 declare under penalty of perjury that the above information is true and correct. _______________________ _________________________________________________ Date Signature of Applicant NOTICE TO PRISONER: A prisoner seeking to proceed without prepayment of fees shall submit an affidavit stating all assets. In addition, a prisoner must attach a statement certififed by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account.