Davis v. U.S. Attorney General, et al

Filing 79

MINUTE ORDER: The 77 Motion Requesting To: Refiled filed 6/23/2014 and the 78 Letter filed by plaintiff on 11/17/2014 is GRANTED in part. If plaintiff seeks to assert new claims in a lawsuit, he must file a new case and may not assert such claims in the above-captioned closed case. Otherwise, the relief requested in the Motion Requesting To: Refiled and the letter filed 11/17/2014 is DENIED. By Judge Robert E. Blackburn on 2/27/2015. (Attachments: # 1 1983 Form, # 2 IFP Form)(alowe)

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF COLORADO

Civil Action No.
(To be supplied by the court)

, Plaintiff,

v.

, Defendant(s).

PRISONER'S MOTION AND AFFIDAVIT
FOR LEAVE TO PROCEED PURSUANT TO 28 U.S.C. § 1915

I request leave to commence this civil action without prepayment of fees or security
therefor pursuant to 28 U.S.C. § 1915. In support of my request, I declare that:
1.

I am unable to pay such fees or give security therefor.

2.

I am entitled to redress.

3.

The nature of this action is:

(Rev. 10/01/12)

4.

My assets and their value are listed below: (attach an additional page if necessary)
(Assets may include income from employment, rent payments, interest or dividends, pensions, annuities, life
insurance payments, Social Security, Veteran's Administration benefits, disability pensions, Worker's
Compensation, unemployment benefits, gifts or inheritances, cash, funds in bank accounts, real estate,
stocks, bonds, notes, automobiles or other valuable property (excluding ordinary household furnishings and
clothing), or any other source of income.)

5.

Are you in imminent danger of serious physical injury?
Yes

No (CHECK ONE). If you answered yes, briefly explain your answer:

6.

I have attached to this motion a signed authorization directing my custodian to calculate
and disburse funds from my inmate trust fund account or institutional equivalent to pay
the required filing fee.

7.

I have attached to this motion a certificate from the appropriate official at each penal
institution in which I have been confined during the six-month period immediately
preceding the filing of this action and a certified copy of my inmate trust fund account
statement for the same six-month period.

DECLARATION UNDER PENALTY OF PERJURY
I declare under penalty of perjury that the information in this motion and affidavit is true
and correct. See 28 U.S.C. § 1746; 18 U.S.C. § 1621.
Executed on
(Date)

(Prisoner’s Original Signature)

(Rev. 10/01/12)

2

AUTHORIZATION
I,
, request and authorize the agency holding me in
custody to calculate and disburse funds from my inmate trust fund account or institutional
equivalent in the amounts specified by 28 U.S.C. § 1915(b). This authorization is furnished in
connection with this civil action and I understand that the total filing fee of $350.00 is due and
will be paid from my inmate trust fund account or institutional equivalent regardless of the
outcome of this case.

Prisoner Name (please print):
Prisoner Signature:

CERTIFICATE OF PRISON OFFICIAL
I certify that the attached statement is an accurate copy of the inmate trust fund account
statement or institutional equivalent for the past six months for the prisoner named below.

Prisoner’s Name:
Signature of Authorized Prison Official:
Date: