Williams v. Schulties et al

Filing 3

ORDER to Submit Application to Proceed in Forma Pauperis or Pay Filing Fee Within 45 Days, signed by Magistrate Judge Sandra M. Snyder on 1/22/2009. IFP Deadline due by 3/11/2009. (Attachments: # 1 Application to Proceed in Forma Pauperis)(Sondheim, M)

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Name:___________________________________ CDC No:_________________________________ Address:_________________________________ _________________________________________ U N IT E D STATES DISTRICT COURT E A S T E R N DISTRICT OF CALIFORNIA FRESNO DIVISION CASE NUMBER: Plaintiff/Petitioner, vs. APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER Defendants/Respondent. / 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. section 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? State the place of your incarceration. 2. Are you currently employed (includes prison employment)? a. b. If the answer is "yes" state the amount of your pay. 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. Yes No Yes No (If "no" DO NOT USE THIS FORM) 3. Have you received any money from the following sources over the last twelve months? a. b. Business, profession, or other self-employment: Rent payments, interest or dividends: -1Yes Yes No No c. d. e.. f. Pensions, annuities or life insurance payments: Disability or workers compensation payments: Gifts or inheritances: Any other sources: Yes Yes Yes Yes No No No No If the answer to any of the above is "yes," describe by that item each source of money. Also state the amount received and what you expect you will continue to receive (attach an additional sheet if necessary). 4. Do you have cash (includes balance of checking or savings accounts)? If "yes" state the total amount: Yes No 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 all persons dependent on you for support, stating your relationship to each person listed and how much you contribute to their support. IMPORTANT: This form must be dated and signed below in order for the court to consider your application. 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. section 1915(b)(2). DATE SIGNATURE OF APPLICANT NOTE: Within sixty days from the date of this application you must forward to the court a certified copy of your prison trust account statement showing transactions for the past six months. (Revised 01/2008) -2-

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