Opinion
No. C 11-02736 EJD (PR).
October 21, 2011
ORDER GRANTING EXTENSION OF TIME TO FILE COMPLETE IN FORMA PAUPERIS APPLICATION
On June 7, 2011, Plaintiff initiated the instant civil rights action in pro se pursuant to 42 U.S.C. § 1983, by filing a letter asserting violations of his constitutional rights. On the same day, the Clerk sent Plaintiff notice that he must either pay the filing fee or file an In Forma Pauperis ("IFP") Application to proceed with this action. (Docket No. 3.) Plaintiff thereafter filed an IFP application which is deficient because the attached Certificate of Funds in Prisoner's Account was not completed by an authorized prison official. (Docket No. 6.) In the interest of justice, the Court will grant an extension of time to file a completed Certificate of Funds in Prisoner's Account to complete Plaintiff's IFP application.
Plaintiff shall submit the missing document within thirty (30) days of the date this order is filed. Failure to file the necessary document will result in the denial of the application to proceed in forma pauperis , and the complete filing fee will be immediately due.
DATED: October 20, 2011
INSTRUCTIONS FOR PRISONER'S IN FORMA PAUPERIS APPLICATION
You must submit to the court a completed Prisoner's In Forma Pauperis Application if you are unable to pay the entire filing fee at the time you file your complaint or petition. Your application must include copies of the prisoner trust account statement showing transactions for the last six months and a certificate of funds in prisoner's account, signed by an authorized officer of the institution.A. Non-habeas Civil Actions
Effective April 9, 2006, the filing fee for any civil action other than a habeas is $350.00. Even if you are granted leave to proceed in forma pauperis, you must still pay the full amount of the court's filing fee, but the fee will be paid in several installments. 28 U.S.C. § 1915.
You must pay an initial partial filing fee of 20 percent of the greater of (a) the average monthly deposits to your account for the 6-month period immediately before the complaint was filed or (b) the average monthly balance in your account for the 6-month period immediately before the complaint was filed. The court will use the information provided on the certificate of funds and the trust account statement to determine the filing fee immediately due and will send instructions to you and the prison trust account office for payment if in forma pauperis status is granted.
After the initial partial filing fee is paid, your prison's trust account office will forward to the court each month 20 percent of the most recent month's income to your prison trust account, to the extent the account balance exceeds ten dollars ($10.00). Monthly payments will be required until the full filing fee is paid. If you have no funds over ten dollars ($10.00) in your account, you will not be required to pay part of the filing fee that month.
If your application to proceed in forma pauperis is granted, you will be liable for the full $350.00 filing fee even if your civil action is dismissed. That means the court will continue to collect payments until the entire filing fee is paid. However, if you do not submit this completed application the action will be dismissed without prejudice and the filing fee will not be collected.
B. Habeas Actions
in forma pauperis in forma pauperis If you use a habeas form to file a non-habeas civil action, you will be required to pay the $350.00 filing fee applicable to all non-habeas civil actions. UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA PRISONER'S APPLICATION TO PROCEED IN FORMA PAUPERIS
) ) ) Plaintiff, ) CASE NO. ________________ ) vs. ) ) ) ) Defendant. ) __________________________ ) I, _____________________, declare, under penalty of perjury that I am the plaintiff in the above entitled case and that the information I offer throughout this application is true and correct. I offer this application in support of my request to proceed without being required to prepay the full amount of fees, costs or give security. I state that because of my poverty I am unable to pay the costs of this action or give security, and that I believe that I am entitled to relief.In support of this application, I provide the following information:
1. Are you presently employed? Yes ___ No ___
If your answer is "yes," state both your gross and net salary or wages per month, and give the name and address of your employer:
Gross: _______________________ Net: _____________________________
Employer: _______________________________________________________
_________________________________________________________________
If the answer is "no," state the date of last employment and the amount of the gross and net salary and wages per month which you received. (If you are imprisoned, specify the last place of employment prior to imprisonment.)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
2. Have you received, within the past twelve (12) months, any money from any of the following sources:
a. Business, Profession or Yes ___ No ___ self employment b. Income from stocks, bonds, Yes ___ No ___ or royalties? c. Rent payments? Yes ___ No ___ d. Pensions, annuities, or Yes ___ No ___ life insurance payments? e. Federal or State welfare payments, Yes ___ No ___ Social Security or other govern- ment source? If the answer is "yes" to any of the above, describe each source of money and state the amount received from each._________________________________________________________________
_________________________________________________________________
3. Are you married? Yes ___ No ___ Spouse's Full Name: _____________________________________________Spouse's Place of Employment: ___________________________________
Spouse's Monthly Salary, Wages or Income:
Gross $ ________________________ Net $ __________________________
4. a. List amount you contribute to your spouse's support:$ ________________ b. List the persons other than your spouse who are dependent upon you for support and indicate how much you contribute toward their support. (NOTE: For minor children, list only their initials and ages. DO NOT INCLUDE THEIR NAMES.). __________________________________________________________________________________________________________________________________
5. Do you own or are you buying a home? Yes ___ No ___ Estimated Market Value: $ ____________ Amount of Mortgage: $ ____________ 6. Do you own an automobile? Yes ___ No ___ Make _________________ Year ________________ Model ___________________Is it financed? Yes ______ No ______ If so, Total due: $ _____________
Monthly Payment: $ ______________
7. Do you have a bank account? Yes ___ No ___ (Do not include account numbers.) Name(s) and address(es) of bank: __________________________________
_________________________________________________________________
Present balance(s): $ ____________________________________________
Do you own any cash? Yes ___ No ___ Amount: $ ______________________
Do you have any other assets? (If "yes," provide a description of each asset and its estimated market value.) Yes ___ No ___
_______________________________________________________________
8. What are your monthly expenses?
Rent: $ ____________________________ Utilities: ____________________________
Food: $ ____________________________ Clothing: _____________________________
Charge Accounts:Name of Account Monthly Payment Total Owed on This Acct.
_____________________ $ _____________________ $ _____________________ _____________________ $ _____________________ $ _____________________ _____________________ $ _____________________ $ _____________________9. Do you have any other debts? (List current obligations, indicating amounts and to whom they are payable. Do not include account numbers.)
_________________________________________________________________
_____________________________________________________________
10. Does the complaint which you are seeking to file raise claims that have been presented in other lawsuits? Yes ___ No ___
Please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in which they were filed.
_________________________________________________________________
______________________________________________________________
I consent to prison officials withdrawing from my trust account and paying to the court the initial partial filing fee and all installment payments required by the court.
I declare under the penalty of perjury that the foregoing is true and correct and understand that a false statement herein may result in the dismissal of my claims.
_______________ __________________________________ DATE SIGNATURE OF APPLICANT Case Number: ___________________CERTIFICATE OF FUNDS IN PRISONER'S ACCOUNT
I certify that attached hereto is a true and correct copy of the prisoner's trust account statement showing transactions of _____________________ [prisoner name] for the last six months ______________________________ [name of institution] where (s)he is confined.I further certify that the average deposits each month to this prisoner's account for the most recent 6-month period were $ __________ and the average balance in the prisoner's account each month for the most recent 6-month period was $ __________.
Dated: __________ _______________________________________________ [Authorized officer of the institution]