Thomas Bodnar v. Maddax et al

Filing 7

ORDER GRANTING 2 Motion to Proceed IFP ; ORDER DIRECTING Payment of Inmate Filing Fee by the Sheriff of Riverside County, signed by Magistrate Judge Erica P. Grosjean on 06/30/2017. (Copy of this order and IFP Application forwarded to Financial -Sacramento and Sheriff of Riverside County) (Attachments: # 1 IFP Application) (Martin-Gill, S)

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Case 1:17-cv-00845-EPG Document 2 Filed 06/20/17 Page 1 of 2 FILED CLERIC,II DISTRICT COIIRT .S. JUN 20 2017 CEIVTRAI DISTRICT OF CALIF'ORPT7A , ~ : RS D~~ UNIT~ll STATES DISTRICT COURT CEn'TRAL DISTRICT OF CALIFOR1~fIA CASE NUMBER .'I7 5 -CV-Oa275-DSF-PLA PRISO2~IER/PLAINTFFF, v. a;z t ~ _ -~ , REQUEST TQ PROCEED WI`THOUf PR~PA~'MENT ELF FILING FEES ~~YIT Ii DECLARATION IN SUPPQRT ~ ~. —~"` -F I,l ~ ;~~1Gt~ ~" ~~. 5~ ,declare under penalty of perjury, that the fo,Ilowing is true and aonect; that I am the prisoner-plaintiff in the above entitled case; trEat in support of my request to proceed r~ithout pr`paymEnt of fees under 28 U.S.C, Section 1915,I declare that b~~cause of my poverty I am unabl e to pay the full cost: ~ 'said p:~ceedings ar to give security therefore and that I am eaatled to redress. I ft :rth~r 3eciare under penatty ofperjury that the responses wtc~ch I have r.~ade to the quesrians and instructions below are true, correct and complete. 1. ~`.:e; : ~.r::_atiy e:nplayed inprison7 DYes ~To ~ 1. ; . answer is yes,state the number of hours you work per reek and the hourly rate ofpay: b. F the place of your mcarcerat~on , fl.:mot ~ ~ ~~ `a+.~• '~ i~c>r.F t~~..r.. ~ri ^a'~~ t~:~r-.w~c^" t,~a.~ ~ r.v ~ ~~y ~ :: the ir. '~.tution fill out the Certificate portion of '~.~ this application and attach a certified copy of your prison ~-asr account ~tatemcnt showing transactions for the past Jix. monti~s.'This c a.,.~v,~'« ~ ~. ~c~e:~ ~► ~~ ~n ~~ ~ t ',`. ,~ `>` :: ~-~ _ , t{ 2. Have ~~ou received, within thepast twelve m.onihs, any money from any of the following sources? a. ~ .sn~ss, p: ~fesson or form of self-employment? Yes „(~}No b. F~ ezt payments, interest or dividends? ❑Yes ~Io c. pensions, annuities or life insurance payments? Yes f~10 d. Gifts or inheritances? DYes fJNo e. Any other income (other than listed above)? Yes C~No f Loans? . rJYes ~No f I the answer to any ofthe above is yes, describe such sourc e of money and state the amount received source during the past twelve(12) months: CV~60P (04/Ofi) BEQUEST TO PROCEED WITHOUT PREPA YMENT Qf FILING FEES WITH from each DECLARATION IN SUPPOI~T Page I of3 Case 1:17-cv-00845-EPG Document 2 Filed 06/20/17 Page 2 of 2 3. Do you own any cash, or do yov have money in a checl~ing or savings account? (Include any funds in ptison accounts, ifapplicable.) O Yes L 5 7No If the answer is yes, identify each account and separ ately state the amount of money held in e c account ~'or each of ation, die sz(6) mo~rlhs prior to the date of this declar 4 Do you own any reat estate,stocks, bonds . , notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothinp~? ❑Ye s Io I the answer is yes, describe the property and state f it approxirzlate value: ' S, In what year did you }ast fle an Income Tax Return? ~...~+.~~ ~:.~': ,.,~.;:~ r ~:RApproximately how rnuck~ income did your last tax return reflect? _~.~~ ~6 r=~.: F . - .~ -, _~_ 6 List the persons wha are dependent upon your . for suppo much you oontribate toward heir support: rt, state your relationship W those persons, and indicata how ~ J~ J I understand that a false statement or answe r td any question in this dec}aration will subje ct me to penalties for perjury. I further understand that perjtuy is punis hable by a term ofimprisonment ofup to fve(5)yeazs and/or a fine of$250,000(18 U.S.C. Sections 1621, 3571). C~ 7 r t ~ F~ ?~ „P.~ :~ State I ~? c~t~c~~ , ~t ~ 1 ~, ti ~ County(or City) .~ ..declare under penalty ofperjury that the foregoing is true and coaect. f~ Date ~ d~' ,b ~~4~{.'l~-~ ~~ $,.`~" `~ IY~'s~ , .]4~ ,1 g w PrisDnerlPIa~intiff(Signature) ~~~ 4~JQ';" .$.f,~ i ., ~`'"d;'4"? l S~ `~ - i '9'~k ? t',7 ~5{ r ' o 3i~`a ~' Ey~'C'4~'C~l `.t.74~ 9,?~t ~5 v'~. may . ;7M: ?• : i t~ p Pc C'i'~ n y ~ + 3~`Lb+~ ~ T~`'1's ^~ t $ j r r ~~t5~5 ~'b"~"5~~; e~~ ~~^~~ „~Iit..~ r i~+~s~P~~a.~t ~ t~~f^r,?, z.~,+~.5 ~a~~.~ `~c~+, ~ ri3 ~`~. :~ 'F9 s~,I r4`~ ~ ~ "~ ~~- w CV-60P (04/06) REQUEST TO PROCEED WITHOUT PREPAYM. ENT OF SILIN G FEES WITH DECLARATION IN SUPP~ R7' Page 2 of3

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