Mozingo v. Fisher et al

Filing 4

ORDER Granting Application To Proceed In Forma Pauperis (ECF No. 3 ), and ORDER Directing Collection Of Inmate Filing Fee By California Department Of Corrections, signed by Magistrate Judge Barbara A. McAuliffe on 5/5/2015. (Attachments: # 1 IFP Application filed 4/23/2015) (Fahrney, E)

Case 1:15-cv-00633-LJO-BAM Document 3 Filed 04/23/15 Page 1 of 3

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF CALIFORNIA

JAMES MOZINGO

APPLICATION TO PROCEED
IN FORMA PAUPERIS
BY A PRISONER

Plaintiff
vs.

RAYTHEL FISHER JR., et al.
CASE NUMBER: 1:15-at-00336

Defendant

't

I, ;
~V\'t::.j j2t,~ I Vi. c / i ~ .~ c'., , declare that I am the plaintiff in the above-entitled
proceeding; that, in support 0 my request t~proceed without prepayment of fees under 28 U.S.C. § 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.

L\

In support of this application, I answer the following questions under penalty of petjury:
1. Are you currently incarcerated:

"&l Yes

If "Yes" state the place of your incarceration.

0 No (If "No" DO NOT USE THIS FORM)

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({" '" (\ 't"'w~iA \) 16 \\ , /'; b {['

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. Are you currently employed?

0

Yes

biNo

a.

If the answer is "Yes" state the amount of your pay.

b.

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.

, 70 c..
"

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3. In the past twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment

DYes

'~o

b. Rent pu},ments, interest or dividends

DYes

~No

c. Pensions, annuities or life insurance payments

DYes

'~No

d. Disability or workers compensation payments

DYes

:RNo

e. Gifts or inheritances

DYes

~No

f. Any other sources

DYes

"SNo

If the answer to any of the above is "Yes" describe by that item each source of money and state the amount
received and what you expect you will continue to receive. Please attach an additional sheet if necessary.
IFPFORM Revised 5/99

1

Case 1:15-cv-00633-LJO-BAM Document 3 Filed 04/23/15 Page 2 of 3

If "Yes" state the total amount:

&No

DYes

4. Do you have cash or checking or savings accounts?

----------------

5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other

.tRl No

0 Yes

valuable property?

If "Yes" describe the property and state its value. ______________________________

6. Do you have any other assets?

DYes

Ja. No

If "Yes" list the asset(s) and state the value of each asset listed.

7. List the persons who are dependent on you for support, state your relationship to each person and indicate
how much you contribute to their support.

I hereby authorize the agency having custody of me to collect from my trust account and forward to the
Clerk of the United Stares District Court payments in accordance with 28 U.S.c. § 1915(b)(2).

I declare under penalty of perjury that the above information is true and correct.

OF APPLICANT

DATE

CERTIFICATE
(To be completed by the institution of incarceration)
I certify that the applicant named herein has the sum of $__________ on account to hislher credit at
_____________________ (name of institution). I further certify that during the past six months
the applicant's average monthly balance was $_ _ _ _ _. I further certify that during the past six months the
average of monthly deposits to the applicant's account was $_ _ _ __
(Please attach a certified copy of the applicant's trust account statement showing transactions for the past six
months.)

DATE

SIGNATURE OF AUTHORIZED OFFICER

2

Verified: _ _ _ Page 3 _ 3
Document 3 Filed 04/23/15 _ _ _ _of _ _ _ _ __
COCR
Inmate Statement Report

Date\Time: 21212015 Case 1:15-cv-00633-LJO-BAM
12:44:45 PM
Institution: VSP
CDCR#

Inmate/Group Name

Institution

Unit

Cell/Bed

AR8313

MOZINGO. JAMES

VSP

D 0021

014004

$0.00

Current Available Balance:

ITransaction list
Transaction
Institution
Date

Source Doc#

Transaction Type

Receipt#lCheck#

Amount

Account Balance

**No information was found for the given criteria. **

IEncumbrance List
Encumbrance Type

Amount

Transaction Date

**No information was found for the given criteria.**

I Obljgation List
Original Owed Balance

Sum of Tx for Date
Range for Oblg

Current Balance

READERS 052714
VSP

$9.00

$0.00

$8.99

REGULAR MAIL

AUG14 082814 VSP

$1.19

$0.00

$1 .19

REGULAR MAIL

SEP14 090814 VSP

$2 .03

$0.00

$2.03

REGULAR MAIL

SEP14 092914 VSP

$5.32

$0.00

$5.32

MEDICAL COPAY

1414912 VSP
011415

$5.00

$0.00

$5.00

Obligation Type

CourtCase#

READING GLASSES

I Restitytion list
Restitution

CourtCase#

Status

RESTITUTION
FINE

FCR299865

Active

Original Owed Balance Interest Accrued

Sum of Tx for Date
Range for Oblg

Current Balance

$0.00

$0.00

$240.50

$280.00

2661