Opinion
1:21-cv-00697-NONE-SKO
07-19-2021
Dae Henderson JR, Plaintiff/Petitioner, v. Jeffrey y. Hamilton, Jr. Defendants/Respondent.
APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER
I. Dae: Henderson, 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. §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? X Yes No (If "no" DO NOT USE THIS FORM) State the place of your incarceration. Sierra Conservation Center
2. Are you currently employed (includes prison employment)? ____ Yes ___ No
a. If the answer is "yes" state the amount of your pay.
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. Re Gifts or inheritances: ____ Yes No
f. Any other sources: X 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 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? X. 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: Security Agreement (Seems as above)
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 provide a certified copy of my trust account statement for activity covering the last six months to the Court. Additionally, once eligibility is established, I further 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).