Williams v. Alfaro

Filing 4

ORDER TO SUBMIT Application to Proceed In Forma Pauperis or Pay Filing Fee Within 45 Days signed by Magistrate Judge Michael J. Seng on 10/7/2017. (Attachments: # 1 IFP Application). (Jessen, A)

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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

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