Opinion
ORDER
EDMUND F. BRENNAN, Magistrate Judge.
Petitioner is a state prisoner without counsel seeking a writ of habeas corpus pursuant to 28 U.S.C. § 2254.
A petitioner seeking a writ of habeas corpus either must pay the $5.00 filing fee, see 28 U.S.C. § 1914(a), or request leave of court to proceed in forma pauperis, 28 U.S.C. § 1915(a).
Petitioner has neither paid the fee nor submitted an application for leave to proceed in forma pauperis.
Within 30 days from the day this order is served, petitioner may submit either the filing fee or the application required by section 1915(a). Petitioner's failure to comply with this order will result in a recommendation that this action be dismissed. The Clerk of the Court is directed to mail to petitioner a form application for leave to proceed in forma pauperis.
So ordered.
I, _______________, declare that I am the petitioner 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 petition.
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.
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 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 $_____________.