Howard v. Wang, et al.
ORDER to Submit Signed Application to Proceed in Forma Pauperis or Pay Filing Fee Withing Thirty (30) Days, signed by Magistrate Judge Gerald B. Cohn on 9/30/2010. IFP Deadline: 11/2/2010. (Attachments: # 1 IFP Application)(Verduzco, M)
(PC) Howard v. Wang, et al.
Doc. 4 Att. 1
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 RIGHTS ACTION, $5.00 FOR A HABEAS CORPUS PETITION, OR $455.00 FOR AN APPEAL. 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. 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. The court will order the agency that has custody of you to take the filing fee out of your prison or jail trust account if there are available funds, and to forward the money to the court. 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 will 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, habeas corpus petition, or appeal. You must 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. 2. 3. 4. Your allegation of poverty is untrue; The action is frivolous or malicious; Your complaint does not state a claim on which relief can be granted, or 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.
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)
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).
Do you have cash (includes balance of checking or savings accounts)? If "yes" state the total amount:
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:
Do you have any other assets?
If "yes," list the asset(s) and state the value of each asset listed:
List all persons dependent on you for support, stating your relationship to each person listed and how much you contribute to their support.
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).
SIGNATURE OF APPLICANT
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.
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