Gomez v. Chief Medical Officer et al
ORDER to Submit Application to Proceed In Forma Pauperis or Pay Filing Fee within 45 Days, signed by Magistrate Judge Sheila K. Oberto on 07/19/2011. (45-Day Deadline) (Attachments: # 1 IFP APPLICATION)(Martin-Gill, S)
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
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.
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF CALIFORNIA
APPLICATION TO PROCEED
IN FORMA PAUPERIS
BY A PRISONER
, 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:
Are you currently incarcerated?
No (If “no” DO NOT USE THIS FORM)
State the place of your incarceration.
Are you currently employed (includes prison employment)?
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.
Have you received any money from the following sources over the last twelve months?
Business, profession, or other self-employment:
Rent payments, interest or dividends:
Pensions, annuities or life insurance payments:
Disability or workers compensation payments:
Gifts or inheritances:
Any other sources:
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
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?
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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