Opinion
CIVIL 3:22-cv-00803-JR
06-07-2022
MARIA JOHNSON, Plaintiffs, v. MATT BERNARD, et al., Defendants
APPLICATION TO PROCEED IN FORMA PAUPERIS
I, __, declare that I am the plaintiff in the above-entitled proceeding. 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 or petition.
In support of this application, I answer the following questions:
1. Are you currently incarcerated? [ ]Yes [ ] No
If "Yes," state the place of your incarceration: ___
If "Yes" and you are filing a civil action or habeas corpus proceeding, have the institution fill out the Certificate portion of this application and attach a certified copy of your prison trust account showing transactions for the past six (6) months.
2. Are you currently employed? [ ] Yes [ ] No [ ] Self-employed
a. If the answer is "Yes," state:
Employees name:___
Employees address:____
Amount of take-home pay or wages: $___per___(specify pay period)
b. If the answer is "No," state:
Name of last employer: ____
Address of last employer: ___
Date of last employment:___
Amount of take-home salary or wages: $__per ___(specify pay period)
3. Is your spouse employed? [ ] Yes [ ] No [ ] Self-employed [ ] Not applicable
a. If the answer is "Yes," state:
Employees name: ___
Employees address:___
Amount of take-home pay or wages: $___per___(specify pay period)
b. Do you have access to your spouse's funds to pay the filing fee in this case? [ ] Yes [ ] No
Please explain your answer below: _____
c. If your spouse's income or assets are available to you to pay the filing fee in this case, would your spouse have enough money left to pay for his or her own expenses?
[ ] Yes [ ] No If the answer is "No," please explain below:___
4. In the past 12 months have you received any money from any of the following sources?
a. Business, profession, or other self-employment [ ] Yes [ ] No
If "Yes," state: Amount received: $_____
Amount expected in future: $ ____
b. Rent payments, interest, or dividends [ ] Yes [ ] No
If "Yes," state: Amount received: $_____
Amount expected in future: $____
c. Pensions, annuities, or life insurance payments [ ] Yes [ ] No
If "Yes," state: Amount received: $___
Amount expected in future: $____
d. Disability or workers' compensation payments [ ] Yes [ ] No
If "Yes," state: Amount received: $___
Amount expected in future: $ ____
e. Gifts or inheritances [ ] Yes [ ] No
If "Yes," state: Amount received: $____
Amount expected in future: $___
f. Any other sources [ ] Yes [ ] No
If "Yes," state: Source: _____
Amount received: $ ____
Amount expected in future: $ ____
5. Do you have cash or checking or savings accounts? [ ] Yes [ ] No (including prison trust accounts)?
If "Yes," state the total amount: $_______
6. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles, or other valuable property? [ ] Yes [ ]No
If "Yes," describe the asset(s) and state the value of each asset listed:____
7. Do you have any other assets? [ ] Yes [ ] No
If "Yes," list the asset(s) and state the value of each asset listed:___
8. Do you have any housing, transportation, utilities, or loan payments, or other regular monthly expenses? [ ] Yes [ ] No
If "Yes," describe and provide the amount of the monthly expense:___
9. List the persons (or, if under 18, initials only) who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support:____
10. Do you have any debts or financial obligations? [ ] Yes [ ] No
If "Yes," describe the amounts owed and to whom they are payable:____
If I am incarcerated and filing a prisoner civil rights complaint, 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 toward the full filing fee of $350.00 for a prisoner civil rights complaint, in accordance with 28 U.S.C. § 1915(b).
I declare under penalty of perjury that the above information is true and correct.
DATE ___SIGNATURE OF APPLICANT___
PRINTED NAME OF APPLICANT____
CERTIFICATE
(To be completed by the institution of incarceration.)
I certify that ___(name of applicant) 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 $___.
I have attached a certified copy of the applicant's trust account statement showing the transactions for the past six months.
DATE ___SIGNATURE OF AUTHORIZED OFFICER___