Opinion
No. CIV S-08-0007 MCE DAD P.
January 15, 2008
ORDER
Plaintiff, an inmate at the Rio Cosumnes Correctional Center, is proceeding pro se and has filed a civil rights action pursuant to 42 U.S.C. § 1983 together with an application to proceed in forma pauperis pursuant to 28 U.S.C. § 1915.
Plaintiff's in forma pauperis application is incomplete and plaintiff did not attach a certified copy of his inmate trust account statement for the six-month period immediately preceding the filing of the complaint in this action. See 28 U.S.C. § 1915(a)(2). Plaintiff will be granted thirty days to submit a new application and a certified copy of his inmate trust account statement for the relevant six-month period.
The court is required to screen complaints brought by prisoners seeking relief against a governmental entity or an officer or employee of a governmental entity. See 28 U.S.C. § 1915A(a). The court must dismiss a complaint or portion thereof if the prisoner has raised claims that are legally "frivolous or malicious," that fail to state a claim upon which relief may be granted, or that seek monetary relief from a defendant who is immune from such relief.See 28 U.S.C. § 1915A(b)(1) (2).
A claim is legally frivolous when it lacks an arguable basis either in law or in fact. Neitzke v. Williams, 490 U.S. 319, 325 (1989); Franklin v. Murphy, 745 F.2d 1221, 1227-28 (9th Cir. 1984). The court may, therefore, dismiss a claim as frivolous where it is based on an indisputably meritless legal theory or where the factual contentions are clearly baseless. Neitzke, 490 U.S. at 327. The critical inquiry is whether a constitutional claim, however inartfully pleaded, has an arguable legal and factual basis. See Jackson v. Arizona, 885 F.2d 639, 640 (9th Cir. 1989); Franklin, 745 F.2d at 1227.
A claim should be dismissed for failure to state a claim upon which relief may be granted only if it appears beyond doubt that plaintiff can prove no set of facts in support of the claim that would entitle him to relief. Hishon v. King Spalding, 467 U.S. 69, 73 (1984) (citing Conley v. Gibson, 355 U.S. 41, 45-46 (1957)); Palmer v. Roosevelt Lake Log Owners Ass'n, 651 F.2d 1289, 1294 (9th Cir. 1981). In reviewing a complaint under this standard, the court must accept as true the allegations of the complaint. See Hospital Bldg. Co. v. Rex Hosp. Trustees, 425 U.S. 738, 740 (1976). The court must also construe the pleading in the light most favorable to the plaintiff and resolve all doubts in the plaintiff's favor. See Jenkins v. McKeithen, 395 U.S. 411, 421 (1969).
Here, plaintiff contends that he received inadequate medical care in that defendant nurse Benton did not order his seizure medication for four days and plaintiff was told that the medication was too costly. Plaintiff has not provided any factual allegations concerning the other defendants named in his complaint. Plaintiff also seeks the following relief: "I want people to be fired There [sic] licence [sic] revolked [sic] and compenstion [sic] for damages[.]" (Compl. at 4.)
The court will dismiss plaintiff's complaint and grant him leave to file an amended complaint. Plaintiff is advised of the following legal standards for a medical care claim.
Under 42 U.S.C. § 1983, to maintain an Eighth Amendment claim based on prison medical treatment, an inmate must show "deliberate indifference to serious medical needs." Estelle v. Gamble, 429 U.S. 97, 104, 97 S. Ct. 285, 50 L. Ed. 2d 251 (1976). In the Ninth Circuit, the test for deliberate indifference consists of two parts. McGuckin v. Smith, 974 F.2d 1050 (9th Cir. 1991), overruled on other grounds by WMX Techs., Inc. v. Miller, 104 F.3d 1133 (9th Cir. 1997) (en banc). First, the plaintiff must show a "serious medical need" by demonstrating that "failure to treat a prisoner's condition could result in further significant injury or the `unnecessary and wanton infliction of pain.'" Id. at 1059 (citing Estelle, 429 U.S. at 104, 97 S. Ct. 285). Second, the plaintiff must show the defendant's response to the need was deliberately indifferent. Id. at 1060. This second prong — defendant's response to the need was deliberately indifferent — is satisfied by showing (a) a purposeful act or failure to respond to a prisoner's pain or possible medical need and (b) harm caused by the indifference. Id. Indifference "may appear when prison officials deny, delay, or intentionally interfere with medical treatment, or it may be shown by the way in which prison physicians provide medical care." Id. at 1059 (quoting Hutchinson v. United States, 838 F.2d 390, 392 (9th Cir. 1988). Yet, an "inadvertent [or negligent] failure to provide adequate medical care" alone does not state a claim under § 1983. Id. (citing Estelle, 429 U.S. at 105, 97 S. Ct. 285). A prisoner need not show his harm was substantial; however, such would provide additional support for the inmate's claim that the defendant was deliberately indifferent to his needs. Id. at 1060. If the harm is an "isolated exception" to the defendant's "overall treatment of the prisoner [it] ordinarily militates against a finding of deliberate indifference." Id. (citations omitted).Jett v. Penner, 439 F.3d 1091, 1096 (9th Cir. 2006).
In his amended complaint, plaintiff must provide additional factual allegations that demonstrate that each named defendant was deliberately indifferent about plaintiff's medical care. Plaintiff should also clarify whether he was denied all seizure medication or whether he was provided alternative medication, and explain how he was harmed by the alleged delay in obtaining his medication. Plaintiff should provide specific dates of medical appointments, the dates when he was without medication and any other critical information, including the dates when the alleged events occurred, in support of his claim. If plaintiff has documents that verify that he requires specific medication, he should attach to his amended complaint copies of those records.
The amended complaint must allege in specific terms how each named defendant was involved in the deprivation of plaintiff's rights. There can be no liability under 42 U.S.C. § 1983 unless there is some affirmative link or connection between a defendant's actions and the claimed deprivation. Rizzo v. Goode, 423 U.S. 362 (1976); May v. Enomoto, 633 F.2d 164, 167 (9th Cir. 1980); Johnson v. Duffy, 588 F.2d 740, 743 (9th Cir. 1978). Vague and conclusory allegations of official participation in civil rights violations are not sufficient. Ivey v. Board of Regents, 673 F.2d 266, 268 (9th Cir. 1982).
Plaintiff is advised that although he may seek monetary compensation, the court will not order that certain defendants be fired or that their license be revoked because such relief is beyond the court's authority to award. Accordingly, in his amended complaint plaintiff should not seek such relief.
Plaintiff is informed that the court cannot refer to a prior pleading in order to make plaintiff's amended complaint complete. Local Rule 15-220 requires that an amended complaint be complete in itself without reference to any prior pleading. This is because, as a general rule, an amended complaint supersedes the original complaint. See Loux v. Rhay, 375 F.2d 55, 57 (9th Cir. 1967). Once plaintiff files an amended complaint, the original pleading no longer serves any function in the case. Therefore, in an amended complaint, as in an original complaint, each claim and the involvement of each defendant must be sufficiently alleged.
On January 9, 2008, plaintiff requested the appointment of counsel. The United States Supreme Court has ruled that district courts lack authority to require counsel to represent indigent prisoners in § 1983 cases. Mallard v. United States Dist. Court, 490 U.S. 296, 298 (1989). In certain exceptional circumstances, the district court may request the voluntary assistance of counsel pursuant to 28 U.S.C. § 1915(e)(1).Terrell v. Brewer, 935 F.2d 1015, 1017 (9th Cir. 1991); Wood v. Housewright, 900 F.2d 1332, 1335-36 (9th Cir. 1990).
The test for exceptional circumstances requires the court to evaluate the plaintiff's likelihood of success on the merits and the ability of the plaintiff to articulate his claims pro se in light of the complexity of the legal issues involved. See Wilborn v. Escalderon, 789 F.2d 1328, 1331 (9th Cir. 1986); Weygandt v. Look, 718 F.2d 952, 954 (9th Cir. 1983). Circumstances common to most prisoners, such as lack of legal education and limited law library access, do not establish exceptional circumstances that would warrant a request for voluntary assistance of counsel. In the present case, the court does not find the required exceptional circumstances.
Accordingly, IT IS HEREBY ORDERED that:
1. Within thirty days from the date of this order, plaintiff shall file a new application for requesting leave to proceed in forma pauperis and plaintiff must provide a certified copy of plaintiff's inmate trust account statement for the six-month period immediately preceding the filing of the complaint in this action.
2. Plaintiff's complaint is dismissed.
3. Plaintiff is granted thirty days from the date of this order to file an amended complaint that complies with the requirements of the Civil Rights Act, the Federal Rules of Civil Procedure, and the Local Rules of Practice; the amended complaint must bear the docket number assigned to this case and must be labeled "Amended Complaint"; plaintiff shall use the form complaint provided by the court.
4. Plaintiff's January 9, 2008 request for the appointment of counsel is denied.
5. The Clerk of the Court is directed to provide plaintiff with the court's form application for requesting leave to proceed in forma pauperis by a prisoner and the form complaint for a § 1983 action.
6. Plaintiff's failure to comply with this order will result in a recommendation that this action be dismissed without prejudice.
INSTRUCTIONS FOR FILING A COMPLAINT BY A PRISONER UNDER THE CIVIL RIGHTS STATUTE, 42 U.S.C. § 1983
I. Scope of Section 1983
An action under Section 1983 is available to challenge violations of the federal constitution or federal statutes which affect the conditions of your confinement or your treatment by government employees while in custody. Although you may ask for and obtain money damages or an injunction under Section 1983, the court cannot issue an order which could affect the length of your sentence in any way. Those types of claims may only be raised through a petition for a writ of habeas corpus. If you want to file a petition for a writ of habeas corpus, you must do so on the correct forms, which are provided by the Clerk of the Court on request.II. Packet
Three copies of a complaint form are attached to this instruction sheet. In addition, included in the packet are an information sheet for prisoners seeking leave to proceed in forma pauperis (without prepayment of filing fees) and two copies of an application to proceed in forma pauperis. To start an action, the following items must be included:
1. An original and one copy of the complaint. You must keep an additional copy of the complaint for your own records. All copies of the complaint must be identical to the original.
2. Either a completed in forma pauperis application or the $350.00 filing fee.
III. Complaint Form
Your complaint must be legibly handwritten or typewritten. You must sign each copy of the complaint and declare under penalty of perjury that the facts stated in the complaint are correct. If you need additional space to answer a question, you should attach an additional blank page. You are required to state facts in support of each claim. The complaint should refer to the provision of the federal constitution or federal law on which you are relying, but should not contain legal arguments or citations.
IV. Venue
Your complaint should be brought in the Sacramento Division of this court only if one or more of the named defendants is located in the Sacramento Division of the Eastern District of California or if your claim arose in the Sacramento Division of this district. The Sacramento Division of the Eastern District of California is comprised of the following counties: Alpine, Amador, Butte, Colusa, El Dorado, Glenn, Lassen, Modoc, Mono, Nevada, Placer, Plumas, Sacramento, San Joaquin, Shasta, Sierra, Siskiyou, Solano, Sutter, Tehama, Trinity, Yolo, and Yuba.
Your complaint should be brought in the Fresno Division of this court only if one or more of the named defendants is located in the Fresno Division of the Eastern District of California or if your claim arose in the Fresno Division of this district. The Fresno Division of the Eastern District of California is comprised of the following counties: Fresno, Calaveras, Inyo, Kern, Kings, Madera, Mariposa, Merced, Stanislaus, Tulare, and Tuolumne.
V. Mailing the Forms
When all of the forms described in part II are completed, if you are bringing your case in the Sacramento Division, mail the original and copies to:
Clerk of the U.S. District Court
for the Eastern District of California 501 I Street, Room 4-400 Sacramento, California 95814
If you are bringing your case in the Fresno Division, mail the original and copies to:
Clerk of the U.S. District Court
for the Eastern District of California
2500 Tulare Street
Fresno, California 93721
VI. After the Complaint is Filed
Once the complaint is filed, the court will review it and decide whether to order service of the complaint on the defendants. You will be sent a copy of any order the court issues. Because of the large volume of cases filed by inmates pending in this court, the court WILL NOT ANSWER INQUIRIES concerning the status of your complaint.
You must keep the Clerk of the Court informed of any change of address. If you fail to do so, the Clerk cannot be responsible for your failure to receive Court orders. This could result in the dismissal of your suit.
The Clerk of the Court does not provide copies of documents to litigants, Copies of any volume may be obtained from Attorney's Diversified Services (ADS): 1424 21st Street, Sacramento, CA 95814. Their phone number is 916-441-4396. We will, however, provide copies of dockets at the rate of fifty cents ($0.50) per page. Checks in the exact amount are made payable to "Clerk, USDC." In forma pauperis status does not waive the cost of copies. Therefore you must keep copies of all documents submitted to the court for your own records.
IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF CALIFORNIA
FORM TO BE USED BY A PRISONER IN FILING A COMPLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983 facts ______________________________ ___________________ (Name of Plaintiff) (Case Number) ______________________________ (Address of Plaintiff) ______________________________ vs. COMPLAINT ______________________________ ______________________________ ______________________________ (Names of Defendants) I. Previous Lawsuits: A. Have you brought any other lawsuits while a prisoner: Yes No B. If your answer to A is yes, how many?: __________ Describe the lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on another piece of paper using the same outline.) 1. Parties to this previous lawsuit: Plaintiff _____________________________________________________________________________ _____________________________________________________________________________________________________ Defendants ____________________________________________________________________________ _______________________________________________________________________________________ Rev'd 5/99 2. Court (if Federal Court, give name of District; if State Court, give name of County) _______________________________________________________________________________________________ 3. Docket Number __________________________________________________________________________ 4. Name of judge to whom case was assigned ________________________________________________ 5. Disposition (For example: Was the case dismissed? Was it appealed? Is it still pending?) ______________________________________________________________________________________ 6. Approximate date of filing lawsuit _____________________________________________________ 7. Approximate date of disposition ________________________________________________________ II. Exhaustion of Administrative Remedies A. Is there a grievance procedure available at your institution? Yes No B. Have you filed a grievance concerning the facts relating to this complaint? Yes No If your answer is no, explain why not __________________________________________________ _____________________________________________________________________________________________________ C. Is the grievance process completed? Yes No III. Defendants (In Item A below, place the full name of the defendant in the first blank, his/her official position in the second blank, and his/her place of employment in the third blank. Use item B for the names, positions and places of employment of any additional defendants.) A. Defendant ________________________________________ is employed as _________________________ ___________________________________________________________ at _______________________________ B. Additional defendants _____________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ IV. Statement of Claim (State here as briefly as possible the of your case. Describe how each defendant is involved, including dates and places. Do not give any legal arguments or cite any cases or statutes. Attach extra sheets if necessary.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ V. Relief. (State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or statutes.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Signed this _____ day of _________________________, 20_____. ____________________________________________________________ (Signature of Plaintiff) I declare under penalty of perjury that the foregoing is true and correct. _______________________ ____________________________________________________ (Date) (Signature of Plaintiff)IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF CALIFORNIA
FORM TO BE USED BY A PRISONER IN FILING A COMPLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983 facts ______________________________ ____________________ (Name of Plaintiff) (Case Number) ______________________________ (Address of Plaintiff) ______________________________ vs. COMPLAINT ______________________________ ______________________________ ______________________________ (Names of Defendants) I. Previous Lawsuits: A. Have you brought any other lawsuits while a prisoner: Yes No B. If your answer to A is yes, how many?: __________ Describe the lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on another piece of paper using the same outline.) 1. Parties to this previous lawsuit: Plaintiff _____________________________________________________________________________ _____________________________________________________________________________________________________ Defendants ____________________________________________________________________________ _______________________________________________________________________________________ Rev'd 5/99 2. Court (if Federal Court, give name of District; if State Court, give name of County) _______________________________________________________________________________________________ 3. Docket Number __________________________________________________________________________ 4. Name of judge to whom case was assigned ________________________________________________ 5. Disposition (For example: Was the case dismissed? Was it appealed? Is it still pending?) _______________________________________________________________________________________ 6. Approximate date of filing lawsuit _____________________________________________________ 7. Approximate date of disposition ________________________________________________________ II. Exhaustion of Administrative Remedies A. Is there a grievance procedure available at your institution? Yes No B. Have you filed a grievance concerning the facts relating to this complaint? Yes No If your answer is no, explain why not __________________________________________________ _____________________________________________________________________________________________________ C. Is the grievance process completed? Yes No III. Defendants (In Item A below, place the full name of the defendant in the first blank, his/her official position in the second blank, and his/her place of employment in the third blank. Use item B for the names, positions and places of employment of any additional defendants.) A. Defendant ________________________________________ is employed as ______________________ _______________________________________________ at ___________________________________________ B. Additional defendants _____________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ IV. Statement of Claim (State here as briefly as possible the of your case. Describe how each defendant is involved, including dates and places. Do not give any legal arguments or cite any cases or statutes. Attach extra sheets if necessary.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ V. Relief. (State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or statutes.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Signed this _____ day of _________________________, 20_____. ____________________________________________________________ (Signature of Plaintiff) I declare under penalty of perjury that the foregoing is true and correct. _______________________ ____________________________________________________ (Date) (Signature of Plaintiff)IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF CALIFORNIA
FORM TO BE USED BY A PRISONER IN FILING A COMPLAINT UNDER THE CIVIL RIGHTS ACT, 42 U.S.C. § 1983 facts ______________________________ ___________________ (Name of Plaintiff) (Case Number) ______________________________ (Address of Plaintiff) ______________________________ vs. COMPLAINT ______________________________ ______________________________ ______________________________ (Names of Defendants) I. Previous Lawsuits: A. Have you brought any other lawsuits while a prisoner: Yes No B. If your answer to A is yes, how many?: __________ Describe the lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on another piece of paper using the same outline.) 1. Parties to this previous lawsuit: Plaintiff _____________________________________________________________________________ _____________________________________________________________________________________________________ Defendants ____________________________________________________________________________ _______________________________________________________________________________________ rev'd 5/99 2. Court (if Federal Court, give name of District; if State Court, give name of County) _______________________________________________________________________________________________ 3. Docket Number __________________________________________________________________________ 4. Name of judge to whom case was assigned ________________________________________________ 5. Disposition (For example: Was the case dismissed? Was it appealed? Is it still pending?) _______________________________________________________________________________________ 6. Approximate date of filing lawsuit _____________________________________________________ 7. Approximate date of disposition ________________________________________________________ II. Exhaustion of Administrative Remedies A. Is there a grievance procedure available at your institution? Yes No B. Have you filed a grievance concerning the facts relating to this complaint? Yes No If your answer is no, explain why not __________________________________________________ _____________________________________________________________________________________________________ C. Is the grievance process completed? Yes No III. Defendants (In Item A below, place the full name of the defendant in the first blank, his/her official position in the second blank, and his/her place of employment in the third blank. Use item B for the names, positions and places of employment of any additional defendants.) A. Defendant ________________________________________ is employed as ______________________ _______________________________________________ at ___________________________________________ B. Additional defendants _____________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ IV. Statement of Claim (State here as briefly as possible the of your case. Describe how each defendant is involved, including dates and places. Do not give any legal arguments or cite any cases or statutes. Attach extra sheets if necessary.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ V. Relief. (State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or statutes.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Signed this _____ day of _________________________, 20_____. ____________________________________________________________ (Signature of Plaintiff) I declare under penalty of perjury that the foregoing is true and correct. _______________________ ____________________________________________________ (Date) (Signature of Plaintiff)INFORMATION TO PRISONERS SEEKING LEAVE TO PROCEED WITH A CIVIL ACTION IN FEDERAL COURT IN FORMA PAUPERIS PURSUANT TO 28 U.S.C. § 1915
In accordance with 1996 amendments to the in forma pauperis (IFP) statute, as a prisoner you will be obligated to pay the full filing fee of $350.00 for a civil action. If you later file an appeal, the filing fee for the appeal is $455.00.If you have the money to pay the filing fee, you should send a cashier's check or money order to the court with your complaint, petition, or notice of appeal and, if appropriate, your IFP application.
If you do not have enough money to pay the full filing fee when your action is filed, you can file the action without prepaying the filing fee. However, the court will assess an initial partial filing fee at the time your action is filed. The initial partial filing fee will be equal to 20 percent of the average monthly deposits to your prison or jail account for the six months immediately preceding the filing of the lawsuit, or 20 percent of the average monthly balance in your prison or jail account for that same six month period, whichever is greater. The court will order the agency that has custody of you to take that initial partial filing fee out of your prison or jail account as soon as funds are available and to forward the money to the court.
After the initial partial filing fee has been paid, you will owe the balance of the filing fee. Until the amount of the filing fee is paid in full, each month you will owe 20 percent of your preceding month's income toward the balance. The agency that has custody of you will collect that money and send payments to the court any time the amount in the account exceeds $10.00. The balance of the filing fee may be collected even if the action is later dismissed, summary judgment is granted against you or you fail to prevail at trial.
In order to proceed with an action in forma pauperis you must complete the attached form and return it to the court with your complaint. You must have a prison or jail official complete the Certification section on the back of the form and attach to the form a certified copy of your prison or jail account statement for the last six months. If you submit an incomplete form or do not submit a prison or jail account statement with the form, your request to proceed in forma pauperis will be denied.
Regardless of whether some or all of the filing fee has been paid, the court is required to screen your complaint and to dismiss the complaint if (1) your allegation of poverty is untrue; (2) the action is frivolous or malicious; (3) your complaint does not state a claim on which relief can be granted; or (4) you sue a defendant for money damages and that defendant is immune from liability for money damages.
If you file more than three actions or appeals while you are a prisoner which are dismissed as frivolous or malicious or for failure to state a claim on which relief can be granted, then you will be prohibited from bringing any other actions in forma pauperis unless you are in imminent danger of serious physical injury. APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER CASE NUMBER:
UNITED STATES DISTRICT COURT EASTERN DISTRICT OF CALIFORNIA Plaintiff vs. Defendant 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 and
1. Are you currently incarcerated: Yes No (If "No" DO NOT USE THIS FORM) If "Yes" state the place of your incarceration. ___________________________________ transactions for the past six months. 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. IFPFORM Revised 5/99 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 APPLICANTCERTIFICATE (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 $__________.(Please attach a certified copy of the applicant's trust account statement showing transactions for the past six months.) APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER CASE NUMBER:
_______________ _____________________________________________ DATE SIGNATURE OF AUTHORIZED OFFICER UNITED STATES DISTRICT COURT EASTERN DISTRICT OF CALIFORNIA Plaintiff vs. Defendant(s) 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 APPLICANTCERTIFICATE (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 $__________.(Please attach a certified copy of the applicant's trust account statement showing transactions for the past six months.)
____________________ ____________________________________________________________ DATE SIGNATURE OF AUTHORIZED OFFICER