Cruz v. Savioe
Filing
7
ORDER Granting 6 Motion to Proceed IFP, signed by Magistrate Judge Barbara A. McAuliffe on 11/20/17. (Attachments: # 1 Motion for IFP) (Gonzalez, R)
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1"'--,1
Case 1:17-cv-01474-DAD-BAM Document 6 Filed 11/13/17 Page 1 of 7
CDC No: rtII".,q""·Z9?Y
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~
NOV 13 2017
CLERI<.
.j).
NOV 13 2011
u.s. DISTRICT COURT
~..I(". 7.r~tf> <::'4"..r~"- c.;rv, C'""e. ~~N DISTRICT OF CALIFORNIA.
"---""?
D
BY
CL
!:A.ST~~rWrIAjfI
OEPUTY CLERK
UNITED STATES DISTRICT CO URT
EASTERN DISTRICT OF CALIFORNIA
·'NG,..;9
...._~"'.tI.£~_ ...
CASE NUMBER:
_;;t..,,~".tI.L'" CA";Jt./
l'J1"C;V- 0/ LI7l{- ftI1rr7
Plaintiff/Petitioner,
v.
APPLlCATION TO PROCEED
IN FORMA PAUPERIS
BY A PRISONER
Defendants/Respondent.
----------------------------~/
I, c_.r"'.t.4'"~_ .. ~u.2F~ c~.,,~, 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. § 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 perj ury:
1.
Are you currel:ltly incarcerated?
vYes
_No
(Tf"no" DO NCilT USE THIS FORM)
State the place of your incarceration. C'FL.i-.r~ 4HY J,QrrF,;?Ah..,.."
2.
Are you currently employed (includes prison employment)?
a.
3.
~o
Yes
If the answer is "yes" state the amount of your pay. _ _ _...::.?'
_______
Hav.e you received any money from the following sources over the last twelvemonths?
a.
b.
c.
d.
e.
f.
Business, profession, or other self-employment:
Rent payments, interest or dividends:
Pensions, annuities or life insurance payments:
Disability or workers compensation payments:
Re Gifts or inheritances:
Any other sources:
-
Yes
Yes
Yes
Yes
Yes
Yes
,./' No
~o
vNo
vNo
vNo
vNo·
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).
;...." .J--.•
Case 1:17-cv-01474-DAD-BAM Document 6 Filed 11/13/17 Page 2 of 7
Do you have cash (includes balance of checking or savings accounts)?
4.
Yes
/No
If "yes" state the total amount: _ _~j1I'c-- _ _ __
Do you own any real estate, stocks, bonds, securities, other financial instruments, autof!}obiles or
_Yes
_V"N_,0
other valuable property?
"
5.
If "yes" describe the property and state its value:
v'No
Yes
Do you have any other assets?
6.
If "yes," list the asset(s) and .state the value of each asset listed: ___
N_tlr_""'_E _ _ _ _ __
_
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 provide a certified copy of my trust account
statement for activity covering the last six months to the Court. Additionally, once eligibility is established, I
further 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 accorda~u.s.c. § 1915(b)(2).
IC)- 2"1- 2017
DATE
.
~-T""
SIGNATURE OF APPLICANT
Applicant's CDCR Number (Mandatory forCDCR Applicants):
---'#-'---'A-'-'-A_·-=2'-~...;..,..!.." _ _ _ _ __
_
CERTIFICA TION BELO W IS TO BE COll1PLETED BY
NON-CDCR INCARCERA TED PRISONERS ONLY
CERTIFICATE
(To be completed by the institution of incarceration)
(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
was $
. I further certify that during the Pflst 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
Case 1:17-cv-01474-DAD-BAM Document 6 Filed 11/13/17 Page 3 of 7
CERTIFICATE OF FUNDS
IN
PRISONER'S ACCOUNT
I certify that attached hereto is a true and correct copy the prisoner's trust
account statement showing transactions of:
_Tl<--J<-f_v-,-/..;....,./I,--o _ _
_
I1-,-A---",-;J..-,-cr.!.-7--1-f_ _for the last six months at
KERN VALLEY STATE PRISON where he is confined.
Oq ~~~-<-_~_jl 0 . ~ ~
I further certify that the average- deposits each month -to this prisoner's
account for the most recent 6-month period were $ (f). ({)C) , and the
average balance in the prisoner's account each for the most recent 6-month
period was $ () ·00 .
Date
Verified: _ _ _ _-'----_ _ _ _ _ _ _ __
AM
COCR
Case 1:17-cv-01474-DAD-BAM Document 6 Filed 11/13/17 Page 4 of 7
Inmate Statement Report
Date\Time: 1117/201710:53:11
Institution: KVSP
CDCR#
Inmate/Group Name
Institution
Unit
Cell/Bed
AA2974
TRUILLO, GUILLERMO
PBSP
B 0021
117001
$0.00
Current Available Balance:
[ransaction List
Transaction
Date
Institution
Transaction Type
Source Doc#
Receipt#/Check#
Amount
Account Balance
**No information was found for the given criteria.**
IEncumbrance List
Encumbrance Type
Transaction Date
Amount
**No information was found for the given criteria.**
I Obligation List
Sum of Tx for Date
Range for Oblg
Current Balance
$0.48
$0.00
$0.48
POST2/9/14EN2/13/1
4
$0.48
$0.00
$0.48
REGULAR MAIL
MAIL 2/9/14ENT2/21
$0.48
$0.00
$0.48
PLRA
CV-00975-GSA
$350.00
$0.00
$350.00
PLRA
CV-00976-0LB
$350.00
$0.00
$350.00
PLRA
CV-01215-GSA
$350.00
$0.00
$350.00
COPY CHARGES
COpy
5/22/14E8/7/14
$1.76
$0.00
$1.76
PLRA
CV-01371-0LB
$350.00
$0.00
$350.00
PLRA
CV-00584-AC
$350.00
$0.00
$350.00
PLRA
CV-01370-0LB
$350.00
$0.00
$350.00
PLRA
1:14-CV-01401-BAM
$350.00
$0.00
$350.00
COPY CHARGES
COPY11/21/14ENT1
2/12
$0.70
$0.00
$0.70
PLRA
1:14-CV-01797-0LB
$350.00
$0.00
$350.00
PLRA
APPEAL 1:
14CV01401 BAM
$505.00
oAA&@.
$505.00
PLRA
1: 15-00859-GSA-PC
REGULAR MAIL
POST8/16/15-8/24/15
COPY CHARGES
COPY8/12/15
8/24/15
COpy CHARGES
COPY9/1/15"9/11/15
REGULAR MAIL
101615MAIL 1020
PLRA
15SM0192
Obligation Type
Court C~se#
REGULAR MAIL
POST2/9/14EN2/10/1
4
REGULAR MAIL
REGULAR
~AIL
MAIL 2/11/16E21816
Original Owed Balance
THE WITHIN INSTRUMENT IS A
CORRECT COpy OF THE TRUST
ACCOUNT MAINTAINED BY THIS
ATIeST: /1·2:-("7
L
, I
m / f<' -c ~rql1c-. '-()c//e$O~OO
$350.00
CALIFORNIAj1EPMTMENT OF
I
CQRRECTI
SAN REHABI AT~O
$2.52
0.00
$1.60
$2.00
$0.00
$2.00
$0.49
$0.00
$0.49
$30.00
$0.00
$30.00
$0.49
$0.00
$0.49
PLRA
3: 15-CV-2826-JLS
PCL
$350.00
$0.00
$350.00
PLRA
APPEAL1:
14CV00975SAB
$505.00
$0.00
$505.00
REGULAR MAIL
POST3/27/16-4/20/16
$3.40
$0.00
$3.40
2
Verified: _ _ _ _ _ _ _ _ _ _ _ __
Date\Time: 11/71201710:53:11 AM-.
Institution: KVSP
COCR
Case 1:17-cv-01474-DAD-BAM Document 6 Filed 11/13/17 Page 5 of 7
Inmate Statement Report
Original Owed Balance
Sum of Tx for Date
Range for Oblg
Current Balance
052516MAI L0609
$0.47
$0.00
$0.47
REGULAR MAIL
052516MAIL0609
$0.47
$0.00
$0.47
REGULAR MAIL
052516MAIL0609
$0.68
$0.00
$0.68 .
REGULAR MAIL
061316MAIL0615
$0.47
$0.00
$0.47
REGULAR MAIL
061316MAIL0615
$0.47
$0.00
$0.47
REGULAR MAIL
061316MAIL0615
$2.41
$0.00
$2.41
REGULAR MAIL
062016MAIL0621
$0.47
$0.00
$0.47
REGULAR MAIL
062016MAIL0621
$0.68 .
$0.00
$0.68
REGULAR MAIL
062016MAIL0621
$0.47
$0.00
$0.47
REGULAR MAIL
062216MAIL0623
$1.99
$0.00
$1.99
REGULAR MAIL
062216MAIL0623
$3.04
$0.00
$3.04
REGULAR MAIL
072216MAIL0725
$0.47
$0.00
$0.47
REGULAR MAIL
072216MAIL0725
$0.47
$0.00
$0.47
REGULAR MAIL
072216MAIL0725 .
$0.47
$0.00
$0.47
PLRA
APPEAL1:
14CV00976DLB
$505.00
$0.00
$505.00
PLRA
APPEAL1:
14CV01215SAB
$505.00
$0.00
$505.00
REGULAR MAIL
12/15/16
$0.47
$0.00
$0.47
PLRA
APPEAL1:
14CV01797DLB
$505.00
$0.00
$505.00 .
REGULAR MAIL
POST/E040517
$0.29
THE WITHIN INSTRUMENT IS A $0.00
REGULAR MAIL
POST/E040717
$0.67
CORRECT COPY 0F THE TR
ACCOUNT MAINTAINED BY T
COPY CHARGES
5/14/17
PLRA
APPEAL1:
15CV00859EPG
PLRA
APPEAL1:
14CV01371EPG
PLRA
1:17-CV-00789-GSA
Obligation Type
CourtCase#
REGULAR MAIL
$0.29
E.
AT);~J~~(f- ~(7' J.. r $0.00
utffC,£.
J.-4'n-e ltJe-·{t;h
CAUFOR
DEPARTMENT OF'$O·OO
CORRECTIO S NO RE BIUTATION
c::tI=--..L'l:O.OO
$350.00
$0.67
$0.30
$505.00
$505.00
$350.00
REGULAR MAIL
101117MAIL1012
$0.69
$0.00
$0.69·
REGULAR MAIL
101117MAIL1012
$0.90
$0.00
$0.90
REGULAR MAIL
101117MAIL 1012
$0.69
$0.00
$.0.69
REGULAR MAIL
101117MAIL1012
$0.49
$0.00
$0.49
REGULAR MAIL
101117MAIL 1012
$.1.61
$0.00
$1.61
REGULAR MAIL
101117MAIL 1012
$3.29
$0.00
$3.29
REGULAR MAIL
101117MAIL 1012
$3.29
$0.00
$3.29
REGULAR MAIL
101317MAIL 1013
$0.49
$0.00
$0.49
Restitution List
Restitution
CourtCase#
Status
RESTITUTION
FINE
SCD219793
Active
Original Owed Balance Interest Accrued
Sum of Tx for Date
Range for Oblg
Current Balance
$0.00
$0.00
$92.05
$200.00
3
Case 1:17-cv-01474-DAD-BAM Document 6 Filed 11/13/17 Page 6 of 7
· .,5-"..z-,U:~~,vt~??Z~~~£o -Cj.:pvJz-~·______
DECLARATION IN SUPPORT
Petitioner
OFREQ~ST
TO PROCEED
IN FORIvtA P A lJPERIS
that in support of my motion
without being required to prepay fees, costs or give security therefor, ] stale thaI
10 proceed
because of my poverty J am unable to pay the costs of said proceeding or 10 give security therefor; thai 1 believe 1 am
entitled to re lief.
1.
Are you presently employcd1 Dyes
a. If the amwer is yes, stale the aIDOunt of yom salary or wages per montb, and give the name and address of your
employer. __~_____ ~_ _ _~~_______ ~~________________~~___~_ _ __
b. If the answer is
DO,
stale the date of last employment and the amount of the salarY and wages per month whicb
you received. ___________________..~~----------------~~------------------..
)
2. Haye you received, withiD the past twelve months, any money from any of the following sources?
;L
Business, profession or fOilll of
self-emplo~nt?·
0 yes}(No
~No
b. Rent payments, interest or dividends?
DYes
c. Pensions, annuities
DYes ~No
Of
d, Gifts or inheritanci:s 7
life msurJDCe payments?
DYes
c. Any odler sources?
~No
DYes
'r
~o
1f the answer to any of the above is yes, describe each source of money. and state the amount received from each
during the past (welvc"-fnooths:
3_
_~_ _ _ _~"'--_ _.__.__~."""_ _~_ _ _ _ _ _ _ _ ._.._______~
Do you own any cash, or do you have· money ina checking or savings account?
(Include any funds in prison
oCCQUnLf)
O,:rcs)fNO,
If U1C answer is yes, slale lite lotal value of Ole ilcTm
QWflCi.t _ _~-'--_ _ _..~_ _ _ _ _ _ _ _ _ _~..__..~_ _ _~
-----_
..- . -..
_
..
4. Do you own 1:17-cv-01474-DAD-BAM Document 6 or other valuable property'! (ErcliuJing ordinary
Case any real estate, stocks, bonds, nOtes, autbmobiles, Filed 11/13/17 Page 7 of 7
ha=clolJfurnishings and dothing)
0 Yes}(No
I f tile answer is yes, descnbe the property and state its approximate value:
_--"7/"--Z!
____________
5_ List Ule persons who are dependent upon you fOT SuppOl;l, state your relationship 10 those persons, and indicate how
mucb you contribute toward their support: - - - - - 7 ' = - - - - - - - - - - - - - - - - - - - - -
I, declare (or certify, verify or state) under penalty of perjuryth~the"mg is true and correct.
-EAecuterlO~~-
- -
~~
Dale
Signature ofPetitioner
CERTIFICATE
J hereby certify that the Petitioner herein has the sum of ~_______________ OD account to his credit
at the ___________________________________ . institution where be is
confined. I further certify thai Petitioner likewise has Ibe following secUlities to his credit according to the records of said
institution:
-------
.. -~-.------
A uthorized Officer of jruriturionfTitle of Officer
- - - - - - - - - - - - - - - - - - - - _.._ - - _.._ - - - - - - - - - - - - _ .
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