CIVIL ACTION NO. 3:09cv335-HTW-LRA.
June 8, 2009
LINDA ANDERSON, Magistrate Judge
Upon consideration of the petition filed pursuant to 28 U.S.C. § 2254 by the petitioner in the above entitled action, the court notes that the petitioner failed to file an application to proceed in forma pauperis or pay the $5.00 filing fee. Accordingly, it is hereby
ORDERED:
1. That on or before June 29, 2009, petitioner shall file a completed application for leave to proceed in forma pauperis which is attached, OR pay the $5.00 filing fee. If the petitioner or someone on behalf of the petitioner submits the $5.00 filing fee, there must be a written explanation that the money is being submitted as payment of the filing fee in Civil Action Number 3:09cv335-HTW-LRA on behalf of petitioner, JAMES H. STERN, #130001.
2. That petitioner is informed that his failure to timely comply with the requirements of this order may lead to the dismissal of his petition.
3. The Clerk shall mail the attached in forma pauperis application to the petitioner at his last known address.
MOTION TO PROCEED IN FORMA PAUPERIS
I, _____________________________________ (name), _______________________ (prisoner number), declare that I am the petitioner in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under 28 U.S.C. § 1915 I declare that I am unable to pay the costs of said proceedings or give security therefor; that I believe I am entitled to the relief. AFFIDAVIT IN SUPPORT OF MOTION Signed: ________________________________ Date: ____________________________________ _______________________________________________________________________________________________ In support of this motion, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? ____ Yes ___ No If "yes" state the place of your incarceration _____________________________________________ 2. Are you presently employed (at the institution or otherwise)? ____ Yes ___ No a. If the answer is "yes," state the amount of your salary or wages per month, and give the name and address of your employer. ______________________________________________________ _________________________________________________________________________________________ b. If the answer is "no," state the date of the last employment and the amount of the salary and wages per month which you received. _________________________________________________ _________________________________________________________________________________________ 3. Have you received within the past twelve months any money from any of the following sources? a. Business, profession or form of self-employment? ____ Yes ____ No b. Rent payments, interest or dividends? ____ Yes ____ No c. Pensions, annuities or life insurance payments? ____ Yes ____ No d. Gifts or inheritances? ____ Yes ____ No e. Any other sources? ____ Yes ____ No If the answer to any of the above is "yes," describe each source of money and state the amount received from each during the past twelve months. ___________________________________ ____________________________________________________________________________________________ ___________________________________________________________________________________________. 4. Do you own cash, or do you have money in a checking or savings account? ____ Yes ____ No (Include any funds in prison accounts.) If the answer is "yes," state the total value of the items owned. __________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 5. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? ____ Yes ____ No If the answer is "yes," describe the property and state its approximate value. _____________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 6. List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ I declare (or certify, verify or state) under penalty of perjury that the foregoing is true and correct. Executed on ________________ ___________________________________ Date Signature of Petitioner Certificate
I hereby certify that the petitioner herein has the sum of $ _________ on account to his credit at the _____________________ institution where he is confined. I further certify that petitioner likewise has the following securities to his credit according to the records of said ________________________________ institution: ______________________________________. ___________________________ ______________________________________ Date Authorized Officer of Institution