Osorio v. Wilkie

Filing 4

ORDER. IT IS ORDERED that on or before 5/28/2021, Plaintiff will either pay the full $402 filing fee for a civil action which includes the $350 filing fee and the $52 administrative fee or file with the Court a completed Application to Proceed in Forma Pauperis on this Courts approved form. Signed by Magistrate Judge Daniel J. Albregts on 4/28/2021. (Attachments: # 1 IFP)(Copies have been distributed pursuant to the NEF - JQC)

UNITED STATES DISTRICT COURT
DISTRICT OF NEVADA
INFORMATION FOR FILING AN APPLICATION TO PROCEED
IN FORMA PAUPERIS UNDER 28 U.S.C. § 1915
A.

General Information

Please use the attached form if you are not an inmate. The fee for filing a civil case is
$402 (which includes the $350 filing fee and the $52 administrative fee). If you are unable
to prepay fees or give security for them, you may apply to the court for leave to proceed in
forma pauperis. 28 U.S.C. § 1915; District of Nevada Local Special Rule (“LSR”) 1-1.
If you have the money to pay the full filing fee, please send a check or money order made
payable to “CLERK, U.S. DISTRICT COURT” with your complaint or petition.
B.

Submission of Application

To submit your application to proceed in forma pauperis, complete the attached form and
return the form to the court. If you are a plaintiff and are requesting leave to proceed in forma
pauperis at the beginning of your case, this application should be returned to the court along with
your complaint or petition.
All civil actions must be filed in the clerk’s office for the unofficial division of the court in
which the action allegedly arose. Local Rule (“LR”) IA 1-6, 1-8. The Clerk of the Court maintains
offices in Las Vegas and Reno at the following addresses:
Unofficial Southern Division (Clark, Esmeralda, Lincoln, & Nye counties):
U.S. District Court Office of the Clerk
333 Las Vegas Boulevard, South, Room #1334
Las Vegas, NV 89101
Unofficial Northern Division (all other counties):
U.S. District Court Office of the Clerk
400 S. Virginia Street, Room #301
Reno, NV 89501
C.

Decision

Once the court makes a decision on your application to proceed in forma pauperis, the
court will enter an order in your case. The order may grant, deny, or impose a partial filing fee.
The order may include additional instructions or request additional information.
If the court grants your application to proceed in forma pauperis, the court must screen
your complaint under 28 U.S.C. § 1915(e)(2) to identify cognizable claims and dismiss claims that
are frivolous, malicious, fail to state a claim on which relief may be granted, or seek monetary
relief from a defendant who is immune from such relief. Due to the court’s caseload, the screening
process may take many months.

Revised 12/1/2020

AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)

UNITED STATES DISTRICT COURT
for the
__________ District of __________
)
)
)
)
)

Plaintiff/Petitioner
v.
Defendant/Respondent

Civil Action No.

APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS
(Short Form)
I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings and
that I am entitled to the relief requested.
In support of this application, I answer the following questions under penalty of perjury:
1. If incarcerated. I am being held at:
.
If employed there, or have an account in the institution, I have attached to this document a statement certified by the
appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any
institutional account in my name. I am also submitting a similar statement from any other institution where I was
incarcerated during the last six months.
2. If not incarcerated. If I am employed, my employer’s name and address are:

My gross pay or wages are: $
(specify pay period)

, and my take-home pay or wages are: $

per

.

3. Other Income. In the past 12 months, I have received income from the following sources (check all that apply):
(a) Business, profession, or other self-employment
(b) Rent payments, interest, or dividends
(c) Pension, annuity, or life insurance payments
(d) Disability, or worker’s compensation payments
(e) Gifts, or inheritances
(f) Any other sources

’
’
’
’
’
’

Yes
Yes
Yes
Yes
Yes
Yes

’
’
’
’
’
’

No
No
No
No
No
No

If you answered “Yes” to any question above, describe below or on separate pages each source of money and
state the amount that you received and what you expect to receive in the future.

AO 240 (Rev. 07/10) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form)

4. Amount of money that I have in cash or in a checking or savings account: $

.

5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or
thing of value that I own, including any item of value held in someone else’s name (describe the property and its approximate
value):

6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide
the amount of the monthly expense):

7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship
with each person, and how much I contribute to their support:

8. Any debts or financial obligations (describe the amounts owed and to whom they are payable):

Declaration: I declare under penalty of perjury that the above information is true and understand that a false
statement may result in a dismissal of my claims.

Date:
Applicant’s signature

Printed name

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