Washington v. Gamboa, et al.

Filing 4

ORDER TO SUBMIT Application to Proceed In Forma Pauperis or Pay Filing Fee Within 45 Days signed by Magistrate Judge Erica P. Grosjean on 3/6/2017. (Attachments: # 1 IFP Application). (Jessen, A)

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 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 $505.00 FOR AN APPEAL. If you are not afforded in forma pauperis
status in a Civil Rights Action, you will be required to pay the $350.00 filing fee plus a
$50.00 administrative fee for a total of $400.00.
If you have the money to pay the full filing fee, send a cashier’s check or money order
made payable to the U.S. District 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 facility where you are
held in custody to collect the filing fee from your prison or jail trust account. EACH MONTH
YOU WILL OWE 20 PERCENT OF YOUR PRECEDING MONTH’S INCOME TOWARD
THE BALANCE UNTIL THE FILING FEE IS PAID IN FULL. The facility will forward
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.
The court is required to screen your complaint regardless of the amount of filing fee
paid and will 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 incarcerated that are dismissed as
frivolous, 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.

(Revised 03/2016)

Name:
CDC No:
Address:

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF CALIFORNIA

CASE NUMBER:
Plaintiff/Petitioner,
v.

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?

Yes

No (If “no” DO NOT USE THIS FORM)

State the place of your incarceration.
2.

Are you currently employed (includes prison employment)?

Yes

No

a.
b.

3.

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?
a.

Business, profession, or other self-employment:

Yes

No

b.

Rent payments, interest or dividends:

Yes

No

c.

Pensions, annuities or life insurance payments:

Yes

No

d.

Disability or workers compensation payments:

Yes

No

e.

Gifts or inheritances:

Yes

No

f.

Any other sources:

Yes

No

If the answer to any of the above is “yes,” describe by that item each source of money, state the
amount received, as well as 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)?

Yes

No

If “yes” state the total amount:
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.
_____________________________________________________________________________
_____________________________________________________________________________
This form must be dated and signed below 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. § 1915(b)(2).

DATE

SIGNATURE OF APPLICANT
CERTIFICATE
(To be completed by the institution of incarceration)

I certify that the applicant named herein has the sum of $_________ on account to his/her 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 monthly deposits to the applicants 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