Lopez v. Cash

Filing 12

ORDER GRANTING EXTENSION OF TIME TO FILE COMPLETE IN FORMA PAUPERIS APPLICATION. Plaintiff shall submit the missing document within thirty (30) days of the date this order is filed. Failure to file the necessary document will result in the denial of the application to proceed in forma pauperis, and the complete filing fee will be immediately due. Signed by Judge Edward J. Davila on 10/20/2011. (Attachments: # 1 Certificate of Funds)(ecg, COURT STAFF) (Filed on 10/21/2011)

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1 UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF CALIFORNIA 2 INSTRUCTIONS FOR PRISONER'S IN FORMA PAUPERIS APPLICATION 3 4 6 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. 7 A. 8 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. 5 9 Non-habeas Civil Actions 10 11 12 13 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. 14 15 16 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. 17 18 19 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. 20 B. Habeas Actions 21 22 23 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. 24 25 26 27 28 IFP APPLI.-PRISONER (Rev. 2/05) 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. PRISONER’S APPLICATION TO PROCEED IN FORMA PAUPERIS ) 15 16 I, , declare, under penalty of perjury that I am the 17 plaintiff in the above entitled case and that the information I offer throughout this application 18 is true and correct. I offer this application in support of my request to proceed without being 19 required to prepay the full amount of fees, costs or give security. I state that because of my 20 poverty I am unable to pay the costs of this action or give security, and that I believe that I am 21 entitled to relief. 22 In support of this application, I provide the following information: 23 1. Are you presently employed? Yes No 24 If your answer is "yes," state both your gross and net salary or wages per month, and give the 25 name and address of your employer: 26 Gross: 27 Employer: Net: 28 PRIS. AP P. TO PRO C. IN FO RM A PA UPE RIS -1- 1 If the answer is "no," state the date of last employment and the amount of the gross and net 2 salary and wages per month which you received. (If you are imprisoned, specify the last 3 place of employment prior to imprisonment.) 4 5 6 7 2. 8 following sources: 9 Have you received, within the past twelve (12) months, any money from any of the a. 10 Business, Profession or Yes No Yes No self employment 11 b. 12 Income from stocks, bonds, or royalties? 13 c. Rent payments? Yes No 14 d. Pensions, annuities, or Yes No Yes No 15 life insurance payments? 16 e. Federal or State welfare payments, 17 Social Security or other govern- 18 ment source? 19 If the answer is "yes" to any of the above, describe each source of money and state the amount 20 received from each. 21 22 23 3. Are you married? 24 Spouse's Full Name: 25 Spouse's Place of Employment: 26 Spouse's Monthly Salary, Wages or Income: 27 Gross $ 28 4. a. Yes Net $ List amount you contribute to your spouse's support:$ PRIS. AP P. TO PRO C. IN FO RM A PA UPE RIS -2- No 1 b. List the persons other than your spouse who are dependent upon you for 2 support and indicate how much you contribute toward their support. (NOTE: 3 For minor children, list only their initials and ages. DO NOT INCLUDE 4 THEIR NAMES.). 5 6 7 5. Do you own or are you buying a home? 8 Estimated Market Value: $ 9 6. Yes No Amount of Mortgage: $ Do you own an automobile? 10 Make 11 Is it financed? Yes 12 Year 7. 14 No Monthly Payment: $ 13 Yes Name(s) and address(es) of bank: No Model If so, Total due: $ Do you have a bank account? Yes No (Do not include account numbers.) 15 16 Present balance(s): $ 17 Do you own any cash? Yes 18 Do you have any other assets? (If "yes," provide a description of each asset and its estimated 19 market value.) Yes No Amount: $ No 20 21 8. What are your monthly expenses? 22 Rent: $ Utilities: 23 Food: $ Clothing: 24 Charge Accounts: 25 Name of Account Monthly Payment Total Owed on This Acct. 26 $ $ 27 $ $ 28 $ $ PRIS. AP P. TO PRO C. IN FO RM A PA UPE RIS -3- 1 9. Do you have any other debts? (List current obligations, indicating amounts and to 2 whom they are payable. Do not include account numbers.) 3 4 5 10. Does the complaint which you are seeking to file raise claims that have been presented 6 in other lawsuits? 7 Please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in 8 which they were filed. Yes No 9 10 11 12 13 14 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. 15 16 17 DATE SIGNATURE OF APPLICANT 18 19 20 21 22 23 24 25 26 27 28 PRIS. AP P. TO PRO C. IN FO RM A PA UPE RIS -4- 1 2 Case Number: 3 4 5 6 7 8 CERTIFICATE OF FUNDS 9 IN 10 PRISONER'S ACCOUNT 11 12 13 I certify that attached hereto is a true and correct copy of the prisoner's trust account statement showing transactions of for the last six months [prisoner name] 14 where (s)he is confined. [name of institution] 15 I further certify that the average deposits each month to this prisoner's account for the 16 most recent 6-month period were $ and the average balance in the prisoner's 17 account each month for the most recent 6-month period was $ . 18 19 Dated:_____________ ___________________________________ [Authorized officer of the institution] 20 21 22 23 24 25 26 27 28 -5-

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