Raymond Tafolla, Jr. v. J. Pickett

Filing 4

Minutes (In Chambers): Order to Show Cause Why Petition Should Not Be Summarily Dismissed as Untimely; Order re: Incomplete Request to Proceed In Forma Pauperis by Magistrate Judge Maria A. Audero: Therefore, Petitioner is ORDERED to submit, by no later than December 17, 2020, either (1) the filing fee of $5 or (2) a completed request to proceed in forma pauperis with the required supporting documentation. A form Declaration in Support of Request to Proceed In Forma Pauperis is attached to this Order. (Attachments: #1 Attach.Notice, #2 Attach.IFP) (es)

Petitioner

DECLARATION IN SUPPORT
OF REQUEST
TO PROCEED
IN FORMA PAUPERIS

Respondent(s)

I,

, declare that I am the petitioner in the above entitled case;

that in support of my motion to proceed without being required to prepay fees, costs or give security therefor, I state that
because of my poverty I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am
entitled to relief.

1. Are you presently employed?

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 last employment and the amount of the salary and wages per month which
you received.
2. 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:

3. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison accounts)
Yes
CV-69 (05/18)

No
PETITION FOR WRIT OF HABEAS CORPUS BY A PERSON IN STATE CUSTODY (28 U.S.C. § 2254)

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If the answer is yes, state the total value of the items owned:

4. 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:

5. 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
institution where he is

at the

confined. I further certify that Petitioner likewise has the following securities to his credit according to the records of said
institution:

Date

CV-69 (05/18)

Authorized Officer of Institution/Title of Officer

PETITION FOR WRIT OF HABEAS CORPUS BY A PERSON IN STATE CUSTODY (28 U.S.C. § 2254)

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