Jason Allan Singer v. Matthew Braman et al
Filing
10
ORDER GRANTING In Forma Pauperis Application; ORDER DIRECTING Payment of Inmate Filing Fee by the California Department of Corrections 2 , signed by Magistrate Judge Erica P. Grosjean on 5/31/17. (Attachments: # 1 IFP Application, # 2 Trust Account Statement)(Hellings, J)
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"-FILE
6~.&h!( U.S (M~T~iICT
COUh1'
Case 1:17-cv-00725-EPG Document 2 Filed 05/18/17 Page 1 of 3
~IA'Y I -8 2017
~M1i D18TRICT Of
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5,~~~
Petitioner
Respondent(sJ
I, ~q~,_i
C+1LltC1flN1A
DEPIJTy
DECLARATION IN SUPPORT
OF REQUEST
TO PROCEED
IN FORMA PAUPERIS
~ t. ~i L .
,declare that I am the petitioner in the above entitled case;
~ ~ ~~--~~~~ i<
that in support of my motion to proceed without being required to prepay tees, costs or gi~~e security therefor, I state that
because of my' poverty I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am
entitled to relief.
1. Are you presently employed? ^1"es `~ No
a. If the ans~ti~er is ~•es, state the amount oY ~~our salary or ~~ages per month, and gi~~e the flame anti address of your
en~plo~~er.
b. If the answer is no, state the date of last employment and the amount of the salar~~ and wages per month which
you received.
2. Have you received, within the past twelve months, an}~ money from any of the following sources?
❑Yes
~No
b. Rent payments, interest or di~~idends%
❑Yes
~.I~'o
c. Pensions, annuities or life insurance pa~~ments?
❑Yes
~,1 No
Yes
u No
❑Yes
'~ No
a.
Business, profession or forn~ of self-employment?
d. Gifts or inheritances?
e.
Any other sources?
if the answer to any of the above is ~-es, describe each source of money and state the an~ount received from each
during the past t~vel~~e months: ~ia
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3. Do you own any cash, or do you ha~~e mone}' in a checking or sa~-ings account? (Include ~~~~i~ttin~ds rn prison nccounts)
u Yes
(0,%L ~1
~o
PE'I~ITI01 f'OR WRIT OF HABEAS CORPUS BY A PERSON I'~' STATE CUSTODY (28 C.S.0 § 21;-1)
Page
Case 1:17-cv-00725-EPG Document 2 Filed 05/18/17 Page 2 of 3
If the ans~ti~er is ~-es, state the total ~~alue of the items o~ti~ned:
4. Do you o~+'n any real estate, stocks, bonds, noCes, automobiles, or other valuable propert}'? ('Excluding ordinary
householdfisrnishrr~gs nr~d clothing) ❑Yes `~io
If the answer is yes, describe the propert}' and state its approximate ealue:
5. List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how
m uch you contribute toward their support: ~ ~,
I, declare (or certifi~, verity- or state) under penalty of e ; y that the forea ~
Executed on `
J
is true and correct.
~'
~ Signature of Petitioner
Z.
to
CERTIFICATE
I hereby certify that the Petitioner herein has the sum of $
on account to his credit
at the
institution where he is
confined. I further certif~~ that Petitioner like~~-ise has the follo~+~ing securities to his credit according to the records of said
institution:
Date
CV-69 (OS/l2)
Authori
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