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)

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
,

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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

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REQUEST TQ PROCEED WI`THOUf
PR~PA~'MENT ELF FILING FEES ~~YIT
Ii
DECLARATION IN SUPPQRT

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,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 ~~
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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

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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
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PrisDnerlPIa~intiff(Signature)
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CV-60P (04/06)

REQUEST TO PROCEED WITHOUT PREPAYM.
ENT OF SILIN

G FEES WITH DECLARATION IN SUPP~

R7'
Page 2 of3