Buckley v. Kessler et al

Filing 7

ORDER VACATING ORDER GRANTING LEAVE TO PROCEED IN FORMA PAUPERIS AND DIRECTING PLAINTIFF TO FILE COMPLETED NON-PRISONER IN FORMA PAUPERIS APPLICATION; DIRECTIONS TO CLERK; granting 2 MOTION for Leave to Proceed in forma pauperis filed by Antonio Cortez Buckley; re 6 ORDER GRANTING LEAVE TO PROCEED IN FORMA PAUPERIS. Signed by Judge Jon S. Tigar on July 10, 2013. (Attachments: # 1 Application to Proceed IFP, # 2 Certificate/Proof of Service)(wsn, COURT STAFF) (Filed on 7/10/2013)

Clear Form
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UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF CALIFORNIA

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Plaintiff,

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vs.

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Defendant.

)
)
)
) CASE NO.
)
) APPLICATION TO PROCEED
) IN FORMA PAUPERIS
) (Non-prisoner cases only)
)
)
)

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I,

, declare, under penalty of perjury that I am the plaintiff

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in the above entitled case and that the information I offer throughout this application is true and

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correct. I offer this application in support of my request to proceed without being required to

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prepay the full amount of fees, costs or give security. I state that because of my poverty I am

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unable to pay the costs of this action or give security, and that I believe that I am entitled to relief.

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In support of this application, I provide the following information:

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1.

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If your answer is "yes," state both your gross and net salary or wages per month, and give the

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name and address of your employer:

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Gross:

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Employer:

Are you presently employed?

Yes

No

Net:

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If the answer is "no," state the date of last employment and the amount of the gross and net salary

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and wages per month which you received.

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2.

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following sources:

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Have you received, within the past twelve (12) months, any money from any of the

a.

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Business, Profession or

Yes

No

Yes

No

self employment?

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b.

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Income from stocks, bonds,
or royalties?

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c.

Rent payments?

Yes

No

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d.

Pensions, annuities, or

Yes

No

Yes

No

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life insurance payments?

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e.

Federal or State welfare payments,

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Social Security or other govern-

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ment source?

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If the answer is "yes" to any of the above, describe each source of money and state the amount

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received from each.

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3.

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Spouse's Full Name:

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Spouse's Place of Employment:

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Spouse's Monthly Salary, Wages or Income:

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Gross $

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4.

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Are you married?

Yes

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
and indicate how much you contribute toward their support. (NOTE: For minor

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children, list only their initials and ages. DO NOT INCLUDE THEIR NAMES.)

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5.

Do you own or are you buying a home?

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Estimated Market Value: $

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6.

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Make

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Is it financed? Yes

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Yes

No

Monthly Payment: $

Amount of Mortgage: $

Do you own an automobile?

Yes

Year
No

No

Model
If so, Total due: $

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7.

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Name(s) and address(es) of bank:

Do you have a bank account? Yes

No

(Do not include account numbers.)

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Present balance(s): $

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Do you own any cash? Yes

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Do you have any other assets? (If "yes," provide a description of each asset and its estimated

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market value.)

No

Amount: $

Yes

No

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8.

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Rent: $

Utilities:

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Food: $

Clothing:

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Charge Accounts:

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Name of Account

What are your monthly expenses?

Monthly Payment

Total Owed on This Account

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$

$

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$

$

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$

$

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9.

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they are payable. Do not include account numbers.)

Do you have any other debts? (List current obligations, indicating amounts and to whom

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10.

Does the complaint which you are seeking to file raise claims that have been presented in

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other lawsuits?

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Please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in

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which they were filed.

Yes

No

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I declare under the penalty of perjury that the foregoing is true and correct and understand that a

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false statement herein may result in the dismissal of my claims.

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DATE

SIGNATURE OF APPLICANT

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