Kirk v. Hedgeph et al

Filing 6

ORDER for Plaintiff to Pay Fee or File In Forma Pauperis Application. Signed by Judge Edward M. Chen on 2/27/2013. (Attachments: # 1 Non-Prisoner IFP Application, # 2 Certificate of Service). (emcsec, COURT STAFF) (Filed on 2/27/2013)

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1   2   3   4   5   6   7   8 UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA 9 10 11 Plaintiff, 12 vs. 13 14 Defendant. ) ) ) ) CASE NO. ) ) APPLICATION TO PROCEED ) IN FORMA PAUPERIS ) ) ) ) 15   16 I, , declare, under penalty of perjury that I am the plaintiff   17 in the above entitled case and that the information I offer throughout this application is true and 18 correct. I offer this application in support of my request to proceed without being required to 19 prepay the full amount of fees, costs or give security. I state that because of my poverty I am 20 unable to pay the costs of this action or give security, and that I believe that I am entitled to relief.         21 In support of this application, I provide the following information:   22 1. Are you presently employed? Yes No 23 If your answer is "yes," state both your gross and net salary or wages per month, and give the 24 name and address of your employer: 25 Gross: 26 Employer:       Net:     27   28 If the answer is "no," state the date of last employment and the amount of the gross and net salary       -1- 1 and wages per month which you received.   2   3   4   5 2. Have you received, within the past twelve (12) months, any money from any of the 6 following sources:     7 a. Business, Profession or Yes No Yes No   8 self employment?   9 b. Income from stocks, bonds,   10 or royalties?   11 c. Rent payments? Yes No 12 d. Pensions, annuities, or Yes No Yes No     13 life insurance payments?   14 e. Federal or State welfare payments,   15 Social Security or other govern- 16 ment source?     17 If the answer is "yes" to any of the above, describe each source of money and state the amount 18 received from each.     19   20   21 3. Are you married? Yes 22 Spouse's Full Name: 23 Spouse's Place of Employment: 24 Spouse's Monthly Salary, Wages or Income: 25 Gross $ 26 4. No         Net $   a. List amount you contribute to your spouse's support:$ b. List the persons other than your spouse who are dependent upon you for support   27   28 and indicate how much you contribute toward their support. (NOTE: For minor       -2- 1 children, list only their initials and ages. DO NOT INCLUDE THEIR NAMES.)   2   3   4 5. Do you own or are you buying a home? 5 Estimated Market Value: $ 6 6. 7 Make 8 Is it financed? Yes 9 Yes No Monthly Payment: $   Amount of Mortgage: $   Do you own an automobile? Yes No   Year Model   No If so, Total due: $     10 7. Do you have a bank account? Yes 11 No (Do not include account numbers.) Name(s) and address(es) of bank:     12   13 Present balance(s): $ 14 Do you own any cash? Yes 15 Do you have any other assets? (If "yes," provide a description of each asset and its estimated 16 market value.)   No Amount: $     Yes No   17   18 8. What are your monthly expenses? 19 Rent: $ Utilities: 20 Food: $ Clothing: 21 Charge Accounts: 22 Name of Account         Monthly Payment Total Owed on This Account   23 $ $     24 $   $   25 $ $   26 9. Do you have any other debts? (List current obligations, indicating amounts and to whom 27 they are payable. Do not include account numbers.)     28       -3- 1   2 10. Does the complaint which you are seeking to file raise claims that have been presented in 3 other lawsuits? Yes 4 Please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in 5 which they were filed.   No       6   7   8 I declare under the penalty of perjury that the foregoing is true and correct and understand that a 9 false statement herein may result in the dismissal of my claims.     10   11   12 DATE SIGNATURE OF APPLICANT   13   14   15   16   17   18   19   20   21   22   23   24   25   26   27   28       -4-

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