Spreadbury v. Bitterroot Public Library et al

Filing 15

MOTION for Leave to Proceed in forma pauperis by Plaintiff Michael E. Spreadbury. (ASG, )

FILED

MAY 0 It 2011
IN THE UNITED STATES DISTRICT COUJ(tTRICK E. DUFFY, CLERK
DEPUTY CLERK. MISSOUlA

.

DISTRICT OF MONTANA
Cause No.

CV.... ~\ -

06L{ ....

M-lVM

(to be filled in by Clerk of Court)
(Full name ofPlainti:fflPetitioner and prisoner

number, if any)

Plaintiff/Petitioner,

MOTION TO PROCEED

IN FORMA PAUPERIS

vs.

(Full name of each efendantlRespondent.

Do not use et. al.)

~ t(qr\~~K
Defendants.
1.

My name is _ _
'0\=----.;_\.....:e=-\.t)...;,.~....;.~---:..,_G_'---==$~'
---=~_a.c\-=-1J==-=-V-_I*J _. In this
_
action, I am (check one):

a petitioner / plaintiff ~

o

a defendant
0 _____________________________
other (explain)

2.

In support of my request to proceed without prepayment of fees or costs
under 28 U.S.C. § 1915, I declare I am unable to pay the costs of these
proceedings and am entitled to relief in the action to which I am or will be a
party. In support of this application, I answer the following questions under
penalty of petjury.

3.

Are you currently employed?
A.

Yes

°

NoK

If Yes, state the amount of your take-home salary or wages, your pay

§.'('~~

Last Name ofPlaintiff/Petitioner
Motion to Proceed In Forma Pauperis (Revised 11109)

Page 10/6

period, and the name and address of your employer:

B.

4.

If No, state the date of your last employment, the amount of your

take-home salary or wages, your pay period, and the name and

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address of your last employer:
-t. 9 ~ ,<;)'0 ~b.'N\l-\

Are you married? Yes

0

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No J(.

No ~

A.

IfYes, is your spouse employed? Yes

B.

If Yes, how much does your spouse earn per month?

0

~~

5.

Ifyou are a minor under age 21, what is your parents or guardian's
approximate monthly income? _ _ _ _ _ _ _ __

6.

In the past twelve months, have you received any money from any ofthe
following sources?
A.
Business, profession, or other self-employment
Yes 0
No . fK..
B.
Rent payments, interest, or dividends
Yes 0
No a
C.
Pensions, annuities, or life insurance payments
Yes 0
No C'f
D.
Disability or workers compensation payments
Yes 0
No !:K
E.
Social Security or retirement benefits
Yes 0
No 13­
F. Family or friends
Yes 6
No 0
G. Gifts or inheritances
Yes 0
No ~
H. Any other sources (specify) ~\L.,.y
Yes QJ!'....
No 0
If the answer to any of the above is Yes, describe each source of money,

state the amount received, the frequency with which you receive it, and

what you expect you will continue to receiv~:

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c;

~~ ev\~~"1 ~

7.

~

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Do you have any cash or checking or savings accounts? Yes pL No
If Yes, state the total value of all thrH:

0

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Last Name ofPlaintiff/Petitioner
Motion to Proceed In Forma Pauperi (Revised 11/0

Page 2 of6

f

8.

Do you own any automobiles, real estate, stocks, bonds, securities, trust,
jewelry, art work, other financial instruments, or things of value, including
any item of value held in someone else's name? Yes 0 NoX
If Yes, describe the property and state its approximate value:

9.

Describe and provide the amount of any housing, transportation, utilities,
loan payments, or other regular monthly expenses you may have.
~~

10. Name all persons dependent on you for support. State your relationship to
each person and indicate how much you contribute to their support. If any
of these individuals are under the age of 18, identify them by using their
first and last initials only.
Ne~

11. Describe any debts or financial obligations you have, providing the amounts
owed and to whom they are payable.
.$ \ ~ I OOC> ~ +(,~

~5', Ob\')

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12.
TO BE COMPLETED BY PRISONERS ONLY
NOTE: Prisoners are required to submit an official copy of their inmate trust
account statement for the previous six months in support of this Application.
You may include your account statement with this Application.
A.

State the place ofyour incarceration:

B.

If you have not been incarcerated at your current institution for the
past six months, list all institutions in which you have been
incarcerated in the past six months. State when you entered and when
you left each institution.

C.

If you have not been incarcerated for the past six months, state the
last date on which you were not incarcerated, and list any institutions
at which you were incarcerated before your current one:

~J.bs'r~

Last Name ofPlainli/flPetitioner
Motion to Proceed In Forma Pauperis

evised 11/0

Page 3 of6

D.

Have you begun any other lawsuit while incarcerated or detained in
any facility?
Yes D No 0
(If No, go to Question 12)

E.

For each prior lawsuit you have filed, provide the following
information. Attach additional sheets as necessary.
1.

11.

The parties to the previous lawsuit(s);

111.

The docket number(s) for each prior lawsuit;

IV.

The date( s) on which each lawsuit was filed;

v.

How and when each lawsuit was resolved (For example, was
the case dismissed? Was it settled? Was it appealed? By
whom, plaintiff or defendant? Is the case still pending?);

VI.

Whether the prior lawsuit was based upon the same or similar
facts asserted in this lawsuit; and

Vll.

F.

The court(s) where each lawsuit was filed. (For federal courts,
identify the District; for state courts, identify the county. Do
not include lawsuits filed in the U.S. District Court for the
District of Montana);

Whether any prior lawsuits were dismissed as frivolous,
malicious, or for failure to state a claim, and if so which ones.

If you filed any appeal in any federal court of appeals, name the

Plaintiff/Petitioner_~~'~"
~e2~~h.>=-::.f!4-1-

Last Name of
__
Motion to Proceed In Forma PauperlS'(Revised l1Aj9)

~_ _ _ __

Page 4 of6

court( s) and give the case number( s) and the disposition.

13.

Applicant's Declaration

A.

I understand I must keep the Court informed of my current mailing
address and my failure to do so may result in denial of this
Application without actual notice to me.

B.

I understand the Federal Rules of Civil Procedure prohibit litigants in
non-habeas proceedings from using certain information in documents
submitted to the Court.
In order to comply with these rules, I understand that:

• social security numbers, taxpayer identification numbers, and
financial account numbers must include only the last four digits
(e.g. xxx-xx-5271, xx-xxx5271, xxxxxxxx3567);
• birth dates must include the year of birth only (e.g. xxJxxJ2001);
and
• names of persons under the age of 18 must include initials only
(e.g. L.K.).
If my documents (including exhibits) contain any of the above listed information, I
understand it is my responsibility to black that information out before sending
those documents to the Court. I understand that if I am a habeas litigant I may, but
am not required to, follow these rules.
I understand I am responsible for protecting the privacy ofthis information in a
non-habeas case.
C.

(Prisoners Only): I understand I may not proceed in forma pauperis if
I have filed three lawsuits and/or appeals that were dismissed on

Last Name ofPlaintifJlPetitioner__ __=-=:...:.
~-=\-·.;('e . .~ :.:~:....:....:..r:t-l--------­
Motion to Proceed In Forma Paupe;;;(Revised IlIP9)

Page 5 of6

grounds the action and/or appeal was frivolous or malicious, or failed
to state a claim upon which relief may be granted, unless I am in
imminent danger of serious physical injury. 28 U.S.C. § 1915(g).
D.

I understand the submission of a false statement or answer to any

question in this Application may subject me to penalties for perjury.
I, the Applicant, declare under penalty of perjury that I ye read the
. hi~
above Application and the information I have set fi
true and correct. 28 U.S.C. § 1746; 18.X:. §
.

To be completed by Notary Public:
I hereby certify that on this day the Applicant, f1l\che:t~1 [3 Sf:.(eqc{bv q

personally appeared before me, a Notary Public for the State of Montana. The
Applicant swears or affirms that slbe is the person named in the foregoing
Application, that slbe has read and truthfully completed the contents thereof, and
that slhe has executed the Application by hislber own hand.
The Application was SUBSCRIBED AND SWORN before me this d. day of
mlly
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RITA L GILL

a~TARY PUBLIC for the
State of Montana
Residing at Hamilton, MT
My Comm. Expires
May 10, 2011

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{
- - -.........""---~---:......;;.;...;....-..JNotary Public, State of Montana, County 0 f "
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My Commission Expires _---=-)'_.-_,0_-_0--=-0...:.,1..:.,..1_ _ __
Special Note: Pro Se litigants proceeding in forma pauperis are not exempt from other fees and
costs associated with prosecuting their actions, including but not limited to copying and witness
fees. It is important to realize that even if you are proceeding with an action in forma pauperis,
neither the Court nor the Clerk's office can make copies for you free of charge. Copies of
documents in your file cannot be provided to you by the Clerk's Office without a charge of $0.50
per page which must be pre-paid at the time you make your request. Therefore, you should
always keep a copy, for your own records, of all documents you send to the Court or to the
Clerk's Office.

PlaintifJ7Petitioner_S""""-L'i"Q-,-~-,~b-,~~+-________

Last Name of
__
Motion to Proceed In Forma Pauperis (Revised iT/()f)

Page60f6