(PC) Mejia v. Nguyen et al
ORDER TO SUBMIT Application to Proceed In Forma Pauperis or Pay Filing Fee within 45 Days signed by Magistrate Judge Gary S. Austin on 6/3/2021. (Attachments: # 1 IFP Application)(Sant Agata, S)
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
$52.00 administrative fee for a total of $402.00.
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. The form includes your authorization for the agency having custody of you to
provide a certified copy of your trust account statement for activity covering the last six months
directly to the Court so that your eligibility for in forma pauperis status can be determined. Your
signature on the form also authorizes the agency having custody of you to collect money from
your trust account and forward it to the Clerk of the United States District Court payments if you
are granted in forma pauperis status. 28 U.S.C. § 1915(b)(2). If you are housed at a non-CDCR
facility (such as a local jail or federal facility), you must have your institution complete the
certification on the form and attach a certified copy of your prison or jail account statement for
the last six months.
If you submit an incomplete form or you are ineligible for in forma pauperis status, 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:
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.
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF CALIFORNIA
APPLICATION TO PROCEED
IN FORMA PAUPERIS
BY A PRISONER
, 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 perjury:
Are you currently incarcerated?
No (If “no” DO NOT USE THIS FORM)
State the place of your incarceration.
Are you currently employed (includes prison employment)?
If the answer is “yes” state the amount of your pay.
Have you received any money from the following sources over the last twelve months?
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:
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
Do you have cash (includes balance of checking or savings accounts)?
If “yes” state the total amount:
Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or
other valuable property?
If “yes” describe the property and state its value:
Do you have any other assets?
If “yes,” list the asset(s) and state the value of each asset listed:__________________________
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 accordance with 28 U.S.C. § 1915(b)(2).
SIGNATURE OF APPLICANT
Applicant’s CDCR Number (Mandatory for CDCR Applicants): _____________________________
CERTIFICATION BELOW IS TO BE COMPLETED BY
NON-CDCR INCARCERATED PRISONERS ONLY
(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
SIGNATURE OF AUTHORIZED OFFICER
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