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)

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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) ,.ld 19'1 ') t «: ff ({" '" (\ '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.. " -;r;·J4./ -'~~'1 ·,'A: f3 .f!...e vY'c'__ !.'U.c;,1- 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

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