McClendon v. Colvin

Filing 5

ORDER re 2 MOTION for Leave to Proceed in forma pauperis filed by Stanton McClendon. Signed by Judge Phyllis J. Hamilton on 02/24/2017. (Attachments: # 1 Attachment)(pjhlc2S, COURT STAFF) (Filed on 2/24/2017)

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Clear Form 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 ) (Non-prisoner cases only) ) ) ) 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. 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: Are you presently employed? Yes No 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. 6 following sources: 7 Have you received, within the past twelve (12) months, any money from any of the a. 8 Business, Profession or Yes No Yes No self employment? 9 b. 10 Income from stocks, bonds, 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. 22 Spouse's Full Name: 23 Spouse's Place of Employment: 24 Spouse's Monthly Salary, Wages or Income: 25 Gross $ 26 4. 27 28 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 -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 Year No No Model If so, Total due: $ 10 7. 11 Name(s) and address(es) of bank: Do you have a bank account? Yes No (Do not include account numbers.) 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. 19 Rent: $ Utilities: 20 Food: $ Clothing: 21 Charge Accounts: 22 Name of Account What are your monthly expenses? Monthly Payment Total Owed on This Account 23 $ $ 24 $ $ 25 $ $ 26 9. 27 they are payable. Do not include account numbers.) Do you have any other debts? (List current obligations, indicating amounts and to whom 28 -3- 1 2 10. Does the complaint which you are seeking to file raise claims that have been presented in 3 other lawsuits? 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. Yes 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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