Opinion
No. CIV S-07-0089 LKK KJM P.
May 8, 2007
ORDER
On January 25, 2007, the court ordered plaintiff to submit a completed application to proceed in forma pauperis and a copy of his inmate trust account statement for the last six months. To date, plaintiff has filed only an incomplete IFP application and has not filed a copy of his inmate trust account statement. Good cause appearing, IT IS HEREBY ORDERED that:
1. Plaintiff shall submit, within thirty days from the date of this order, a completed affidavit in support of his request to proceed in forma pauperis on the form provided by the Clerk of Court;
2. The Clerk of the Court is directed to send plaintiff a new Application to Proceed In Forma Pauperis By a Prisoner;
3. Plaintiff shall submit, within thirty days from the date of this order, a certified copy of his prison trust account statement for the last six months; and
4. In the event plaintiff cannot comply with this order due to the actions of prison officials, plaintiff shall submit within thirty days an affidavit indicating that he has complied with all applicable prison procedures in attempting to comply with this order and provide the court with the name of the person at his prison responsible for assisting plaintiff in completing his application to proceed in forma pauperis.
APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER
I, _______________________________________________, 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, 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.In support of this application, I answer the following questions under penalty of perjury: Have the institution fill out the Certificate portion of this application and attach a certified copy of your prison trust account statement showing transactions for the past six months. and
1. Are you currently incarcerated: Yes No (If "No" DO NOT USE THIS FORM) If "Yes" state the place of your incarceration. __________________________________ 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 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 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).I declare under penalty of perjury that the above information is true and correct.
________________ ____________________________________________ DATE SIGNATURE OF APPLICANT