Opinion
1:21-cv-01080-JLT
07-23-2021
DAVID ERNESTO MACKEY, Plaintiff/Petitioner, v. KEVIN M. MOORE, ACCOUNTING OFFICER (SPEC.) DSH-COALINGA NICK J. Office OF HUMAN RIGHTS ANALYST Defendants/Respondent.
APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER
I, DAVID ERNESTO MACKEY___, 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. section 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. DEPT.OF STAE Hospitals COALINGA:
2. Are you currently employed (includes prison employment)? X Yes ___No
a. If the answer is "yes" state the amount of your pay. $200.00-A MONTH.
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. Have you received any money from the following sources over the last twelve months?
a. Business, profession, or other self-employment: ___Yes X No
b. Rent payments, interest or dividends: ___Yes X No
c. Pensions, annuities or life insurance payments: ___Yes X No
d. Disability or workers compensation payments: ___Yes X No
e. Gifts or inheritances: ___Yes X No
f. Any other sources: ___Yes X 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? ___Yes X No
If "yes" describe the property and state its value: ___
6. Do you have any other assets? ___Yes X No
If "yes," list the asset(s) and state the value of each asset listed: ___
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 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).