Malcolm Melvin v. Bureau of Prisons et al

Filing 3

ORDER Summarily Dismissing Section 2241 Habeas Corpus Petition Without Prejudice to Plaintiff's Right to File These Claims in a New Civil-Rights Action by Judge Valerie Baker Fairbank. (Attachments: # 1 Civil Rights Packet) (ec)

UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
INSTRUCTIONS FOR FILING A CIVIL RIGHTS COMPLAINT BY A PRISONERGENERAL INSTRUCTIONS
This package includes the following documents:
4 copies - Complaint form
4 copies- Declaration to proceed without prepayment of filing fees
In order for your complaint to be filed, you must submit the original and two copies of both the complaint and
declaration to the Clerk. The remaining copy of each is for you to keep for your records. Your complaint must be
typewritten or legibly handwritten in ink. You, the plaintiff, must sign and declare under penalty of perjury that the facts
are correct. If you need additional space to answer a question, you must use the reverse side of the form or an additional
blank page. You must file a separate complaint for each claim unless they are all related to the same incident or issue. You
are required to allege facts; not legal arguments or authorities.
FILING FEES
Payment of filing fee required
The filing fee is $350 plus a $50 administrative fee, for a total of $400. However, in accordance with 28 U.S.C. § 1915, as a
prisoner you will only be obligated to pay the filing fee of $350 if your application to proceed in forma pauperis is granted.
If you have the money to pay the filing fee, you should submit a cashier’s check, certified bank check, business or
corporate check, government issued check, or money order drawn on a major America bank or the United States Postal
Service, payable to the Clerk of Court and mail it with your complaint to the address listed on the reverse side of these
instructions. The Clerk’s Office will also accept credit cards (Mastercard/Visa, Discover, American Express) for filing fees
and miscellaneous fees. Credit card payments may be made at all payment windows where receipts are issued.
Request to pay filing fee in monthly installments
If you do not have the money to pay the full filing fee, you must complete the Request to Proceed Without Prepayment of
Filing Fees with Declaration in Support. The Declaration must be returned to the Court with your complaint. NOTE: You
must have a prison or jail official complete the Certification Section on the Declaration and attach to the Declaration
a certified copy of your prison or jail trust account statement for the six months immediately preceding the filing of
the complaint. If you submit an incomplete Declaration or do not submit a prison or jail trust account statement
with the Declaration, your request to proceed without prepayment of the filing fees may be denied.
Initial partial filing fee assessment
If your request to proceed without prepayment of filing fees is granted, 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% of the average monthly deposits to your
prison or jail account for the six months immediately preceding the filing of the action, or 20% 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 forward the money to the Clerk of Court.
Collection of balance of filing fee
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% 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 Clerk of Court any time the amount in your account
exceeds $10.00.

INSTRUCTIONS FOR FILING A CIVIL RIGHTS COMPLAINT BY A PRISONER - GENERAL INSTRUCTIONS
CV-66A (05/13)

PAGE 1 OF 2

DISMISSAL OF THE COMPLAINT
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, you will be prohibited from bringing any other actions in forma
pauperis unless you are in imminent danger of serious physical injury. NOTE: You are required under penalties of
perjury to provide accurate information regarding previous filings. Failure to provide this information may result in
the immediate dismissal of your complaint.
JURISDICTION
To determine whether jurisdiction and venue are proper in this Court:
AGAINST FEDERAL DEFENDANTS, please refer to 28 U.S.C. § 1391(e) and Bivens v. Six Unknown
Federal Narcotics Agents, 403 U.S. 388, 397 (1971);
AGAINST NON-FEDERAL DEFENDANTS, please refer to 28 U.S.C. § 1391(b) for claims brought pursuant
to 42 U.S.C. § 1983.
SERVICE OF THE COMPLAINT
If your request to proceed without prepayment of the filing fees is approved, the Court will determine whether the United
States Marshal should serve the defendant(s) on your behalf.
INQUIRIES AND COPYING REQUESTS
Because of the large volume of cases filed by prisoners in this Court and limited court resources, the Court and Clerk's
Office will not answer inquires concerning the status of your case or provide copies of documents, except at a charge of
fifty cents ($0.50) per page. You must therefore keep copies of all documents submitted to the court for your own records.
TO MAIL THE COMPLAINT
Mail the original and the two copies of the following completed documents to the address below: complaint and
declaration to proceed without prepayment of filing fees (if applicable):
United States District Court
Central District of California
312 North Spring Street, Room G-8
Los Angeles, California 90012
ATTENTION: PRO SE CLERK
Telephone: [phone]

INSTRUCTIONS FOR FILING A CIVIL RIGHTS COMPLAINT BY A PRISONER - GENERAL INSTRUCTIONS
CV-66A (05/13)

PAGE 2 OF 2

FULL NAME
COMMITTED NAME (if different)

FULL ADDRESS INCLUDING NAME OF INSTITUTION

PRISON NUMBER (if applicable)

UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
CASE NUMBER
To be supplied by the Clerk

PLAINTIFF,
v.

DEFENDANT(S).

CIVIL RIGHTS COMPLAINT
PURSUANT TO (Check one)
G 42 U.S.C. § 1983
G Bivens v. Six Unknown Agents 403 U.S. 388 (1971)

A. PREVIOUS LAWSUITS
1. Have you brought any other lawsuits in a federal court while a prisoner: G Yes

G No

2. If your answer to “1.” is yes, how many?
Describe the lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on an
attached piece of paper using the same outline.)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 1 of 6

a. Parties to this previous lawsuit:
Plaintiff
Defendants
b. Court
c. Docket or case number
d. Name of judge to whom case was assigned
e. Disposition (For example: Was the case dismissed? If so, what was the basis for dismissal? Was it
appealed? Is it still pending?)
f.

Issues raised:

g. Approximate date of filing lawsuit:
h. Approximate date of disposition
B. EXHAUSTION OF ADMINISTRATIVE REMEDIES
1. Is there a grievance procedure available at the institution where the events relating to your current complaint
occurred? G Yes G No
2. Have you filed a grievance concerning the facts relating to your current complaint? G Yes

G No

If your answer is no, explain why not

3. Is the grievance procedure completed? G Yes

G No

If your answer is no, explain why not

4. Please attach copies of papers related to the grievance procedure.
C. JURISDICTION
This complaint alleges that the civil rights of plaintiff
(print plaintiff's name)

who presently resides at

(mailing address or place of confinement)

,

were violated by the actions of the defendant(s) named below, which actions were directed against plaintiff at
(institution/city where violation occurred)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 2 of 6

on (date or dates)
NOTE:

(Claim I)

,

(Claim II)

,

(Claim III)

.

You need not name more than one defendant or allege more than one claim. If you are naming more than
five (5) defendants, make a copy of this page to provide the information for additional defendants.

1. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

2. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

3. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 3 of 6

4. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

5. Defendant

resides or works at
(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 4 of 6

D. CLAIMS*
CLAIM I
The following civil right has been violated:

Supporting Facts: Include all facts you consider important. State the facts clearly, in your own words, and without
citing legal authority or argument. Be certain you describe, in separately numbered paragraphs, exactly what each
DEFENDANT (by name) did to violate your right.

*If there is more than one claim, describe the additional claim(s) on another attached piece of paper using the same
outline.
CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 5 of 6

E. REQUEST FOR RELIEF
I believe that I am entitled to the following specific relief:

(Date)

(Signature of Plaintiff)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 6 of 6

FULL NAME
COMMITTED NAME (if different)

FULL ADDRESS INCLUDING NAME OF INSTITUTION

PRISON NUMBER (if applicable)

UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
CASE NUMBER
To be supplied by the Clerk

PLAINTIFF,
v.

DEFENDANT(S).

CIVIL RIGHTS COMPLAINT
PURSUANT TO (Check one)
G 42 U.S.C. § 1983
G Bivens v. Six Unknown Agents 403 U.S. 388 (1971)

A. PREVIOUS LAWSUITS
1. Have you brought any other lawsuits in a federal court while a prisoner: G Yes

G No

2. If your answer to “1.” is yes, how many?
Describe the lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on an
attached piece of paper using the same outline.)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 1 of 6

a. Parties to this previous lawsuit:
Plaintiff
Defendants
b. Court
c. Docket or case number
d. Name of judge to whom case was assigned
e. Disposition (For example: Was the case dismissed? If so, what was the basis for dismissal? Was it
appealed? Is it still pending?)
f.

Issues raised:

g. Approximate date of filing lawsuit:
h. Approximate date of disposition
B. EXHAUSTION OF ADMINISTRATIVE REMEDIES
1. Is there a grievance procedure available at the institution where the events relating to your current complaint
occurred? G Yes G No
2. Have you filed a grievance concerning the facts relating to your current complaint? G Yes

G No

If your answer is no, explain why not

3. Is the grievance procedure completed? G Yes

G No

If your answer is no, explain why not

4. Please attach copies of papers related to the grievance procedure.
C. JURISDICTION
This complaint alleges that the civil rights of plaintiff
(print plaintiff's name)

who presently resides at

(mailing address or place of confinement)

,

were violated by the actions of the defendant(s) named below, which actions were directed against plaintiff at
(institution/city where violation occurred)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 2 of 6

on (date or dates)
NOTE:

(Claim I)

,

(Claim II)

,

(Claim III)

.

You need not name more than one defendant or allege more than one claim. If you are naming more than
five (5) defendants, make a copy of this page to provide the information for additional defendants.

1. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

2. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

3. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 3 of 6

4. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

5. Defendant

resides or works at
(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 4 of 6

D. CLAIMS*
CLAIM I
The following civil right has been violated:

Supporting Facts: Include all facts you consider important. State the facts clearly, in your own words, and without
citing legal authority or argument. Be certain you describe, in separately numbered paragraphs, exactly what each
DEFENDANT (by name) did to violate your right.

*If there is more than one claim, describe the additional claim(s) on another attached piece of paper using the same
outline.
CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 5 of 6

E. REQUEST FOR RELIEF
I believe that I am entitled to the following specific relief:

(Date)

(Signature of Plaintiff)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 6 of 6

FULL NAME
COMMITTED NAME (if different)

FULL ADDRESS INCLUDING NAME OF INSTITUTION

PRISON NUMBER (if applicable)

UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
CASE NUMBER
To be supplied by the Clerk

PLAINTIFF,
v.

DEFENDANT(S).

CIVIL RIGHTS COMPLAINT
PURSUANT TO (Check one)
G 42 U.S.C. § 1983
G Bivens v. Six Unknown Agents 403 U.S. 388 (1971)

A. PREVIOUS LAWSUITS
1. Have you brought any other lawsuits in a federal court while a prisoner: G Yes

G No

2. If your answer to “1.” is yes, how many?
Describe the lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on an
attached piece of paper using the same outline.)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 1 of 6

a. Parties to this previous lawsuit:
Plaintiff
Defendants
b. Court
c. Docket or case number
d. Name of judge to whom case was assigned
e. Disposition (For example: Was the case dismissed? If so, what was the basis for dismissal? Was it
appealed? Is it still pending?)
f.

Issues raised:

g. Approximate date of filing lawsuit:
h. Approximate date of disposition
B. EXHAUSTION OF ADMINISTRATIVE REMEDIES
1. Is there a grievance procedure available at the institution where the events relating to your current complaint
occurred? G Yes G No
2. Have you filed a grievance concerning the facts relating to your current complaint? G Yes

G No

If your answer is no, explain why not

3. Is the grievance procedure completed? G Yes

G No

If your answer is no, explain why not

4. Please attach copies of papers related to the grievance procedure.
C. JURISDICTION
This complaint alleges that the civil rights of plaintiff
(print plaintiff's name)

who presently resides at

(mailing address or place of confinement)

,

were violated by the actions of the defendant(s) named below, which actions were directed against plaintiff at
(institution/city where violation occurred)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 2 of 6

on (date or dates)
NOTE:

(Claim I)

,

(Claim II)

,

(Claim III)

.

You need not name more than one defendant or allege more than one claim. If you are naming more than
five (5) defendants, make a copy of this page to provide the information for additional defendants.

1. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

2. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

3. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 3 of 6

4. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

5. Defendant

resides or works at
(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 4 of 6

D. CLAIMS*
CLAIM I
The following civil right has been violated:

Supporting Facts: Include all facts you consider important. State the facts clearly, in your own words, and without
citing legal authority or argument. Be certain you describe, in separately numbered paragraphs, exactly what each
DEFENDANT (by name) did to violate your right.

*If there is more than one claim, describe the additional claim(s) on another attached piece of paper using the same
outline.
CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 5 of 6

E. REQUEST FOR RELIEF
I believe that I am entitled to the following specific relief:

(Date)

(Signature of Plaintiff)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 6 of 6

FULL NAME
COMMITTED NAME (if different)

FULL ADDRESS INCLUDING NAME OF INSTITUTION

PRISON NUMBER (if applicable)

UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
CASE NUMBER
To be supplied by the Clerk

PLAINTIFF,
v.

DEFENDANT(S).

CIVIL RIGHTS COMPLAINT
PURSUANT TO (Check one)
G 42 U.S.C. § 1983
G Bivens v. Six Unknown Agents 403 U.S. 388 (1971)

A. PREVIOUS LAWSUITS
1. Have you brought any other lawsuits in a federal court while a prisoner: G Yes

G No

2. If your answer to “1.” is yes, how many?
Describe the lawsuit in the space below. (If there is more than one lawsuit, describe the additional lawsuits on an
attached piece of paper using the same outline.)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 1 of 6

a. Parties to this previous lawsuit:
Plaintiff
Defendants
b. Court
c. Docket or case number
d. Name of judge to whom case was assigned
e. Disposition (For example: Was the case dismissed? If so, what was the basis for dismissal? Was it
appealed? Is it still pending?)
f.

Issues raised:

g. Approximate date of filing lawsuit:
h. Approximate date of disposition
B. EXHAUSTION OF ADMINISTRATIVE REMEDIES
1. Is there a grievance procedure available at the institution where the events relating to your current complaint
occurred? G Yes G No
2. Have you filed a grievance concerning the facts relating to your current complaint? G Yes

G No

If your answer is no, explain why not

3. Is the grievance procedure completed? G Yes

G No

If your answer is no, explain why not

4. Please attach copies of papers related to the grievance procedure.
C. JURISDICTION
This complaint alleges that the civil rights of plaintiff
(print plaintiff's name)

who presently resides at

(mailing address or place of confinement)

,

were violated by the actions of the defendant(s) named below, which actions were directed against plaintiff at
(institution/city where violation occurred)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 2 of 6

on (date or dates)
NOTE:

(Claim I)

,

(Claim II)

,

(Claim III)

.

You need not name more than one defendant or allege more than one claim. If you are naming more than
five (5) defendants, make a copy of this page to provide the information for additional defendants.

1. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

2. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

3. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 3 of 6

4. Defendant

resides or works at

(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

5. Defendant

resides or works at
(full name of first defendant)
(full address of first defendant)
(defendant's position and title, if any)

The defendant is sued in his/her (Check one or both): G individual

G official capacity.

Explain how this defendant was acting under color of law:

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 4 of 6

D. CLAIMS*
CLAIM I
The following civil right has been violated:

Supporting Facts: Include all facts you consider important. State the facts clearly, in your own words, and without
citing legal authority or argument. Be certain you describe, in separately numbered paragraphs, exactly what each
DEFENDANT (by name) did to violate your right.

*If there is more than one claim, describe the additional claim(s) on another attached piece of paper using the same
outline.
CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 5 of 6

E. REQUEST FOR RELIEF
I believe that I am entitled to the following specific relief:

(Date)

(Signature of Plaintiff)

CIVIL RIGHTS COMPLAINT
CV-66 (7/97)

Page 6 of 6

UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
CASE NUMBER

PRISONER/PLAINTIFF,
v.

DEFENDANT(S).

REQUEST TO PROCEED WITHOUT
PREPAYMENT OF FILING FEES WITH
DECLARATION IN SUPPORT

, declare under penalty of perjury, that the following is
I,
true and correct; that I am the prisoner-plaintiff in the above entitled case; that in support of my request to proceed
without prepayment of fees under 28 U.S.C. Section 1915, I declare that because of my poverty I am unable to pay the
full costs of said proceedings or to give security therefore and that I am entitled to redress.
I further declare under penalty of perjury that the responses which I have made to the questions and instructions below are
true, correct and complete.
1. Are you presently employed in prison? GYes

GNo

a. If the answer is yes, state the number of hours you work per week and the hourly rate of pay:

b. State the place of your incarceration
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.

.

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?
GYes GNo
b. Rent payments, interest or dividends?
GYes GNo
c. Pensions, annuities or life insurance payments?
GYes GNo
d. Gifts or inheritances?
GYes GNo
e. Any other income (other than listed above)?
GYes GNo
f. Loans?
GYes GNo
If the answer to any of the above is yes, describe such source of money and state the amount received from each
source during the past twelve (12) months:

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 1 of 3

3. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison
accounts, if applicable.) G Yes G No
If the answer is yes, identify each account and separately state the amount of money held in each account for each of
the six (6) months prior to the date of this declaration.

4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary
household furnishings and clothing)? G Yes
G No
If the answer is yes, describe the property and state it approximate value:

5. In what year did you last file an Income Tax Return?
Approximately how much income did your last tax return reflect?
6. List the persons who are dependent upon your for support, state your relationship to those persons, and indicate how
much you contribute toward their support:

I understand that a false statement or answer to any question in this declaration will subject me to penalties for
perjury. I further understand that perjury is punishable by a term of imprisonment of up to five (5) years and/or a fine
of $250,000 (18 U.S.C. Sections 1621, 3571).

State

I,

County (or City)

, declare under penalty of perjury that the foregoing is true and correct.

Date

Prisoner/Plaintiff (Signature)

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 2 of 3

PRISONER AUTHORIZATION
If my request to proceed without prepayment of filing fees is granted, I understand that I am required by statute to pay the
full amount of the filing fees for this case, regardless of my forma pauperis status and the disposition of this case. I
further authorize the prison officials at this institution to assess, collect and forward to the Court the full amount of these
fees, in monthly payments based on the average of deposits to or balance in my prison trust account in accordance with 28
U.S.C. Section 1915.

Prisoner-Plaintiff (Signature)

CERTIFICATE OF AUTHORIZED OFFICER
I hereby certify that the Prisoner-Plaintiff herein has credit in the sum of $
on account at
the
institution where Prisoner-Plaintiff is confined.
I further certify that during the past six months the applicant's average monthly balance was $
certify that during the past six months the average of monthly deposits to the applicant's account was$

. I further
.

A certified copy of the prisoner-plaintiff's trust account statement for the last six (6) months is attached.

Date

Authorized Officer of Institution (Signature)

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 3 of 3

UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
CASE NUMBER

PRISONER/PLAINTIFF,
v.

DEFENDANT(S).

REQUEST TO PROCEED WITHOUT
PREPAYMENT OF FILING FEES WITH
DECLARATION IN SUPPORT

, declare under penalty of perjury, that the following is
I,
true and correct; that I am the prisoner-plaintiff in the above entitled case; that in support of my request to proceed
without prepayment of fees under 28 U.S.C. Section 1915, I declare that because of my poverty I am unable to pay the
full costs of said proceedings or to give security therefore and that I am entitled to redress.
I further declare under penalty of perjury that the responses which I have made to the questions and instructions below are
true, correct and complete.
1. Are you presently employed in prison? GYes

GNo

a. If the answer is yes, state the number of hours you work per week and the hourly rate of pay:

b. State the place of your incarceration
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.

.

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?
GYes GNo
b. Rent payments, interest or dividends?
GYes GNo
c. Pensions, annuities or life insurance payments?
GYes GNo
d. Gifts or inheritances?
GYes GNo
e. Any other income (other than listed above)?
GYes GNo
f. Loans?
GYes GNo
If the answer to any of the above is yes, describe such source of money and state the amount received from each
source during the past twelve (12) months:

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 1 of 3

3. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison
accounts, if applicable.) G Yes G No
If the answer is yes, identify each account and separately state the amount of money held in each account for each of
the six (6) months prior to the date of this declaration.

4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary
household furnishings and clothing)? G Yes
G No
If the answer is yes, describe the property and state it approximate value:

5. In what year did you last file an Income Tax Return?
Approximately how much income did your last tax return reflect?
6. List the persons who are dependent upon your for support, state your relationship to those persons, and indicate how
much you contribute toward their support:

I understand that a false statement or answer to any question in this declaration will subject me to penalties for
perjury. I further understand that perjury is punishable by a term of imprisonment of up to five (5) years and/or a fine
of $250,000 (18 U.S.C. Sections 1621, 3571).

State

I,

County (or City)

, declare under penalty of perjury that the foregoing is true and correct.

Date

Prisoner/Plaintiff (Signature)

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 2 of 3

PRISONER AUTHORIZATION
If my request to proceed without prepayment of filing fees is granted, I understand that I am required by statute to pay the
full amount of the filing fees for this case, regardless of my forma pauperis status and the disposition of this case. I
further authorize the prison officials at this institution to assess, collect and forward to the Court the full amount of these
fees, in monthly payments based on the average of deposits to or balance in my prison trust account in accordance with 28
U.S.C. Section 1915.

Prisoner-Plaintiff (Signature)

CERTIFICATE OF AUTHORIZED OFFICER
I hereby certify that the Prisoner-Plaintiff herein has credit in the sum of $
on account at
the
institution where Prisoner-Plaintiff is confined.
I further certify that during the past six months the applicant's average monthly balance was $
certify that during the past six months the average of monthly deposits to the applicant's account was$

. I further
.

A certified copy of the prisoner-plaintiff's trust account statement for the last six (6) months is attached.

Date

Authorized Officer of Institution (Signature)

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 3 of 3

UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
CASE NUMBER

PRISONER/PLAINTIFF,
v.

DEFENDANT(S).

REQUEST TO PROCEED WITHOUT
PREPAYMENT OF FILING FEES WITH
DECLARATION IN SUPPORT

, declare under penalty of perjury, that the following is
I,
true and correct; that I am the prisoner-plaintiff in the above entitled case; that in support of my request to proceed
without prepayment of fees under 28 U.S.C. Section 1915, I declare that because of my poverty I am unable to pay the
full costs of said proceedings or to give security therefore and that I am entitled to redress.
I further declare under penalty of perjury that the responses which I have made to the questions and instructions below are
true, correct and complete.
1. Are you presently employed in prison? GYes

GNo

a. If the answer is yes, state the number of hours you work per week and the hourly rate of pay:

b. State the place of your incarceration
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.

.

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?
GYes GNo
b. Rent payments, interest or dividends?
GYes GNo
c. Pensions, annuities or life insurance payments?
GYes GNo
d. Gifts or inheritances?
GYes GNo
e. Any other income (other than listed above)?
GYes GNo
f. Loans?
GYes GNo
If the answer to any of the above is yes, describe such source of money and state the amount received from each
source during the past twelve (12) months:

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 1 of 3

3. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison
accounts, if applicable.) G Yes G No
If the answer is yes, identify each account and separately state the amount of money held in each account for each of
the six (6) months prior to the date of this declaration.

4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary
household furnishings and clothing)? G Yes
G No
If the answer is yes, describe the property and state it approximate value:

5. In what year did you last file an Income Tax Return?
Approximately how much income did your last tax return reflect?
6. List the persons who are dependent upon your for support, state your relationship to those persons, and indicate how
much you contribute toward their support:

I understand that a false statement or answer to any question in this declaration will subject me to penalties for
perjury. I further understand that perjury is punishable by a term of imprisonment of up to five (5) years and/or a fine
of $250,000 (18 U.S.C. Sections 1621, 3571).

State

I,

County (or City)

, declare under penalty of perjury that the foregoing is true and correct.

Date

Prisoner/Plaintiff (Signature)

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 2 of 3

PRISONER AUTHORIZATION
If my request to proceed without prepayment of filing fees is granted, I understand that I am required by statute to pay the
full amount of the filing fees for this case, regardless of my forma pauperis status and the disposition of this case. I
further authorize the prison officials at this institution to assess, collect and forward to the Court the full amount of these
fees, in monthly payments based on the average of deposits to or balance in my prison trust account in accordance with 28
U.S.C. Section 1915.

Prisoner-Plaintiff (Signature)

CERTIFICATE OF AUTHORIZED OFFICER
I hereby certify that the Prisoner-Plaintiff herein has credit in the sum of $
on account at
the
institution where Prisoner-Plaintiff is confined.
I further certify that during the past six months the applicant's average monthly balance was $
certify that during the past six months the average of monthly deposits to the applicant's account was$

. I further
.

A certified copy of the prisoner-plaintiff's trust account statement for the last six (6) months is attached.

Date

Authorized Officer of Institution (Signature)

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 3 of 3

UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
CASE NUMBER

PRISONER/PLAINTIFF,
v.

DEFENDANT(S).

REQUEST TO PROCEED WITHOUT
PREPAYMENT OF FILING FEES WITH
DECLARATION IN SUPPORT

, declare under penalty of perjury, that the following is
I,
true and correct; that I am the prisoner-plaintiff in the above entitled case; that in support of my request to proceed
without prepayment of fees under 28 U.S.C. Section 1915, I declare that because of my poverty I am unable to pay the
full costs of said proceedings or to give security therefore and that I am entitled to redress.
I further declare under penalty of perjury that the responses which I have made to the questions and instructions below are
true, correct and complete.
1. Are you presently employed in prison? GYes

GNo

a. If the answer is yes, state the number of hours you work per week and the hourly rate of pay:

b. State the place of your incarceration
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.

.

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?
GYes GNo
b. Rent payments, interest or dividends?
GYes GNo
c. Pensions, annuities or life insurance payments?
GYes GNo
d. Gifts or inheritances?
GYes GNo
e. Any other income (other than listed above)?
GYes GNo
f. Loans?
GYes GNo
If the answer to any of the above is yes, describe such source of money and state the amount received from each
source during the past twelve (12) months:

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 1 of 3

3. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison
accounts, if applicable.) G Yes G No
If the answer is yes, identify each account and separately state the amount of money held in each account for each of
the six (6) months prior to the date of this declaration.

4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary
household furnishings and clothing)? G Yes
G No
If the answer is yes, describe the property and state it approximate value:

5. In what year did you last file an Income Tax Return?
Approximately how much income did your last tax return reflect?
6. List the persons who are dependent upon your for support, state your relationship to those persons, and indicate how
much you contribute toward their support:

I understand that a false statement or answer to any question in this declaration will subject me to penalties for
perjury. I further understand that perjury is punishable by a term of imprisonment of up to five (5) years and/or a fine
of $250,000 (18 U.S.C. Sections 1621, 3571).

State

I,

County (or City)

, declare under penalty of perjury that the foregoing is true and correct.

Date

Prisoner/Plaintiff (Signature)

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 2 of 3

PRISONER AUTHORIZATION
If my request to proceed without prepayment of filing fees is granted, I understand that I am required by statute to pay the
full amount of the filing fees for this case, regardless of my forma pauperis status and the disposition of this case. I
further authorize the prison officials at this institution to assess, collect and forward to the Court the full amount of these
fees, in monthly payments based on the average of deposits to or balance in my prison trust account in accordance with 28
U.S.C. Section 1915.

Prisoner-Plaintiff (Signature)

CERTIFICATE OF AUTHORIZED OFFICER
I hereby certify that the Prisoner-Plaintiff herein has credit in the sum of $
on account at
the
institution where Prisoner-Plaintiff is confined.
I further certify that during the past six months the applicant's average monthly balance was $
certify that during the past six months the average of monthly deposits to the applicant's account was$

. I further
.

A certified copy of the prisoner-plaintiff's trust account statement for the last six (6) months is attached.

Date

Authorized Officer of Institution (Signature)

REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT
CV-60P (04/06)

Page 3 of 3