Chavez v. California Department of Corrections Prison Guards

Filing 5

ORDER GRANTING EXTENSION OF TIME TO FILE COMPLETE IN FORMA PAUPERIS APPLICATION. The Court grants plaintiff an extension of time to file a complete in forma pauperis application, with the necessary supporting documents, within thirty (30) days from t he date this order is filed, or in the alternative, to pay the full $350.00 filing fee. Failure to respond in accordance with this order in the time provided may result in dismissal of this case without prejudice for failure to pay the filing fee without further notice to plaintiff. Signed by Judge James Ware on 10/18/2010. (Attachments: # 1 Prisoner IFP application)(ecg, COURT STAFF) (Filed on 10/19/2010)

Chavez v. California Department of Corrections Prison Guards

Doc. 5 Att. 1

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UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF CALIFORNIA INSTRUCTIONS FOR PRISONER'S IN FORMA PAUPERIS APPLICATION You must submit to the court a completed Prisoner's In Forma Pauperis Application if you are unable to pay the entire filing fee at the time you file your complaint or petition. Your application must include copies of the prisoner trust account statement showing transactions for the last six months and a certificate of funds in prisoner's account, signed by an authorized officer of the institution. A. Non-habeas Civil Actions

Effective April 9, 2006, the filing fee for any civil action other than a habeas is $350.00. Even if you are granted leave to proceed in forma pauperis, you must still pay the full amount of the court's filing fee, but the fee will be paid in several installments. 28 U.S.C. § 1915. You must pay an initial partial filing fee of 20 percent of the greater of (a) the average monthly deposits to your account for the 6-month period immediately before the complaint was filed or (b) the average monthly balance in your account for the 6-month period immediately before the complaint was filed. The court will use the information provided on the certificate of funds and the trust account statement to determine the filing fee immediately due and will send instructions to you and the prison trust account office for payment if in forma pauperis status is granted. After the initial partial filing fee is paid, your prison's trust account office will forward to the court each month 20 percent of the most recent month's income to your prison trust account, to the extent the account balance exceeds ten dollars ($10.00). Monthly payments will be required until the full filing fee is paid. If you have no funds over ten dollars ($10.00) in your account, you will not be required to pay part of the filing fee that month. If your application to proceed in forma pauperis is granted, you will be liable for the full $350.00 filing fee even if your civil action is dismissed. That means the court will continue to collect payments until the entire filing fee is paid. However, if you do not submit this completed application the action will be dismissed without prejudice and the filing fee will not be collected. Habeas Actions

The filing fee for a habeas action is $5.00. If you are granted leave to proceed in forma pauperis you will not be required to pay any portion of this fee. If you are not granted leave to proceed in forma pauperis you must pay the fee in one payment and not in installments. If you use a habeas form to file a non-habeas civil action, you will be required to pay the $350.00 filing fee applicable to all non-habeas civil actions.

I F P APPLI.-PRISONER (Rev. 2/05)

Dockets.Justia.com

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1. I, , declare, under penalty of perjury that I am the Defendant. ) vs. Plaintiff, ) ) ) ) ) ) ) ) ) ) UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA

CASE NO. PRISONER'S APPLICATION TO PROCEED IN FORMA PAUPERIS

plaintiff in the above entitled case and that the information I offer throughout this application is true and correct. I offer this application in support of my request to proceed without being required to prepay the full amount of fees, costs or give security. I state that because of my poverty I am unable to pay the costs of this action or give security, and that I believe that I am entitled to relief. In support of this application, I provide the following information: Are you presently employed? Yes No

If your answer is "yes," state both your gross and net salary or wages per month, and give the name and address of your employer: Gross: Employer: Net:

P R I S . AP P . TO PRO C . IN FO R M A PA U P E R I S

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If the answer is "no," state the date of last employment and the amount of the gross and net salary and wages per month which you received. (If you are imprisoned, specify the last place of employment prior to imprisonment.)

2.

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

following sources: a. Business, Profession or self employment b. Income from stocks, bonds, or royalties? c. d. Rent payments? Pensions, annuities, or life insurance payments? e. Federal or State welfare payments, Social Security or other government source? If the answer is "yes" to any of the above, describe each source of money and state the amount received from each. Yes No Yes Yes No No Yes No Yes No

3.

Are you married?

Yes

No

Spouse's Full Name: Spouse's Place of Employment: Spouse's Monthly Salary, Wages or Income: Gross $ 4. a. Net $ List amount you contribute to your spouse's support:$

P R I S . AP P . TO PRO C . IN FO R M A PA U P E R I S

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

Do you own or are you buying a home?

Yes

No

Estimated Market Value: $ 6. Make Is it financed? Yes Monthly Payment: $ 7. Do you have a bank account? Yes No Do you own an automobile? Year

Amount of Mortgage: $ Yes Model If so, Total due: $ No

No

(Do not include account numbers.)

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

Present balance(s): $ Do you own any cash? Yes No Amount: $

Do you have any other assets? (If "yes," provide a description of each asset and its estimated market value.) Yes No

What are your monthly expenses? Utilities: Clothing:

Rent: $ Food: $ Charge Accounts: Name of Account $ $ $

Monthly Payment $ $ $

Total Owed on This Acct.

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9.

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

whom they are payable. Do not include account numbers.)

10.

Does the complaint which you are seeking to file raise claims that have been presented Yes No

in other lawsuits?

Please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in which they were filed.

I consent to prison officials withdrawing from my trust account and paying to the court the initial partial filing fee and all installment payments required by the court. I declare under the penalty of perjury that the foregoing is true and correct and understand that a false statement herein may result in the dismissal of my claims.

DATE

SIGNATURE OF APPLICANT

P R I S . AP P . TO PRO C . IN FO R M A PA U P E R I S

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[ n a m e of institution]

Case Number:

CERTIFICATE OF FUNDS IN PRISONER'S ACCOUNT

I certify that attached hereto is a true and correct copy of the prisoner's trust account statement showing transactions of
[prisoner name]

for the last six months where (s)he is confined.

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I further certify that the average deposits each month to this prisoner's account for the most recent 6-month period were $ and the average balance in the prisoner's .

account each month for the most recent 6-month period was $

Dated:_____________

___________________________________
[Authorized officer of the institution]

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