Opinion
1:21-cv-00903-SAB
06-07-2021
Ronald W. Ward Plaintiff/Petitioner, v. Christine Raygoza et al, Defendants/Respondent.
APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER
I, Ronald W. Ward, 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:
1. Are you currently incarcerated? XX Yes ___ No (If "no" DO NOT USE THIS FORM) State the place of your incarceration Coalinga State Hospital
2. Are you currently employed, (includes prison employment)? ___ Yes XX No
a. If the answer is "yes" state the amount of your pay. ___________
3. Have you received any money from the following sources over the last twelve months?
a. Business, profession, or other self-employment: ___ Yes XX No
b. Rent payments, interest or dividends: ___ Yes XX No
c. Pensions, annuities or life insurance payments: ___ Yes XX No
d. Disability or workers compensation payments: ___ Yes XX No
e. Re Gifts or inheritances: ___ Yes XX No
f. Any other sources: ___ Yes XX 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 it necessary).
4. Do you have cash (includes balance of checking or savings accounts)? ___ Yes XX 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 XX No
If "yes" describe the property and state its value: _______
6. Do you have any other assets? ___ Yes XX 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.
Ronald W. Ward, self: _________________
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 provide a certified copy of my trust account statement for activity covering the last six months to the Court. Additionally, once eligibility is established, I further 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).
Applicant's CDCR Number (Mandatory for CDCR Applicants): _________
CERTIFICATION BELOW IS TO BE COMPLETED BY NON-CDCR INCARCERATED PRISONERS ONLY
CERTIFICATE
(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 monthly deposits to the applicants account was $ ________.
(Please attach a certified copy of the applicant's trust account statement showing transactions for the past six months.)