Capri v. Sisolak et al
ORDER - Fully complete IFP application, or $402 filing fee, due by 1/17/2023. Clerk shall send P approved IFP form and instructions.(Attached hereto for distribution to P via NNCC law library.) Clerk is directed to retain t he complaint and exhibits (ECF Nos. 1-1, 1-2, 1-3, 1-4, 1-5, 1-6, 1-7, 1-8, 1-9) but not file them at this time. Signed by Magistrate Judge Carla Baldwin on 11/18/2022. (Attachments: # 1 IFP form and Instructions)(Copies have been distributed pursuant to the NEF - DRM)
UNITED STATES DISTRICT COURT
DISTRICT OF NEVADA
INFORMATION FOR FILING AN APPLICATION TO PROCEED
IN FORMA PAUPERIS BY AN INMATE UNDER 28 U.S.C. § 1915
Please use the attached form if you are an inmate. If you are an inmate who is unable to
pay the entire filing fee at the time you file your complaint or petition, you must submit a completed
inmate’s application to proceed in forma pauperis to the court. Nev. Local Special Rule (“LSR”)
1-1. Your application must include copies of your inmate trust account statement for the past six
months and a properly executed financial certificate signed by an authorized officer at your
If you are filing a non-habeas civil action, including a civil rights action pursuant to 42
U.S.C. § 1983, please follow the instructions outlined in Section A. If you are filing a petition for
writ of habeas corpus, please follow the instructions outlined in Section B. To submit your
application, please follow the instructions outlined in Section C.
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.
Non-Habeas Civil Actions
The fee for filing any civil action other than a petition for writ of habeas corpus is $402
(which includes the $350 filing fee and the $52 administrative fee). If you are granted leave to
proceed in forma pauperis, you must still pay the $350 filing fee (but not the $52 administrative
fee) in the form of several installment payments. 28 U.S.C. § 1915(b).
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 financial
certificate and the inmate trust account statement to determine the filing fee immediately due and
will send instructions to you and the prison or jail trust account office for payment if in forma
pauperis status is granted.
After the initial partial filing fee is paid, your prison’s or jail’s trust account office will forward
to the court each month 20 percent of the most recent month’s income from your prison or jail
trust account, to the extent that your account exceeds $10. Monthly payments will be required
until the full filing fee of $350 is paid. If you have no funds over $10 in your account, you will not
be required to pay a part of the filing fee for that month.
If your application to proceed in forma pauperis is granted, you will be liable for the
full $350 filing fee even if your civil action is dismissed. The court will continue to collect
payments until the entire filing fee is paid.
Page 1 of 2
The fee for filing a petition for a writ of habeas corpus is $5. There is no administrative
fee. 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
$5 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
fee applicable to all non-habeas civil actions.
Submission of Application
To submit your application to proceed in forma pauperis, complete the attached form and
return the form to the court with your complaint or petition.
In civil actions filed by pro se (self-represented) inmates, the action must be filed in the
unofficial division of the court in which the inmate is held when the complaint or petition is
submitted for filing. Nev. 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
Please continue to use electronic filing if it is available at your facility or institution.
Page 2 of 2
United States District Court
DISTRICT OF NEVADA
APPLICATION TO PROCEED
IN FORMA PAUPERIS
, declare that I am the (check the appropriate box)
(filing 42 U.S.C. § 1983)
(filing 28 U.S.C. § 2255 motion)
(writ of habeas corpus
28 U.S.C. §§ 2254 or 2241)
in this case. I am unable to prepay the fees of this proceeding or give security because of my
poverty. I acknowledge and consent that a portion of any recovery, as directed by the court, shall
be paid to the clerk for reimbursement of all fees incurred by me as a result of being granted leave
to proceed in forma pauperis.
In further support of this application, I answer the following questions:
Are you presently employed?
If the answer is “yes,” state the amount of your salary or wages per month, and give
the name and address of your employer. (List gross and net salary.)
If the answer is “no,” state the date of last employment and the amount of the salary
or wages per month which you received.
Have you received within the past twelve months any money from any of the following
Business, profession or other form of self-employment?
Rent payments, interest or dividends?
Pensions, annuities or life insurance payments?
Gifts or inheritances?
Any other sources?
If the answer to any of the above is “yes,” describe each source of money and state the
amount received from each during the past twelve months.
Do you own any cash, or do you have money in checking or savings accounts (include any
funds in prison accounts, and any funds on deposit with a bank, saving & loan, etc., outside
the prison) ?
If the answer is “yes,” state the total value and list the location of each account, type of
account, and amount or balance in the account. Do not include your account number(s).
Do you own or have any interest in any real estate, stocks, bonds, notes, trusts, automobiles
or other valuable property (excluding ordinary household furnishings and clothing)?
If the answer is “yes,” describe the property, its location and state its approximate value.
List the persons who are dependent upon you for support, state your relationship to those
persons, and indicate how much you contribute toward their support each month.
Do you receive any income from disability, Social Security or any other pension?
If the answer is “yes,” describe the source and amount received each month.
Have you placed any property, assets or money in the name or custody of anyone else in the
last two years?
If the answer is “yes,” give the date, describe the property, assets or money, give the name
of the person given custody of the item and the reason for the transfer.
I, the undersigned, acknowledge that I have read the foregoing and that the information
contained therein is true and correct to my own knowledge and belief.
Further, I state that I have not directly or indirectly paid or caused to be paid to any inmate,
agent of an inmate, or family member of any inmate a sum of money, favors or anything else for
assistance in the preparation of this document or any other document in connection with this action.
Further, I acknowledge that if any of the information included in this motion for leave to
proceed in forma pauperis is false or misleading, I understand that sanctions may be imposed against
me. Those sanctions may include, but are not limited to, the following:
dismissal of my case with prejudice;
imposition of monetary sanctions;
the Nevada Department of Prisons may bring disciplinary proceedings for a violation
of MJ-48 of the Code of Penal Discipline, which can include all sanctions authorized
under the Code including the loss of good time credits and punitive confinement; and
Further, I hereby authorize the United States District Court, District of Nevada, or its
representative, to investigate my financial status, and authorize any individual, corporation, or
governmental entity to release any such information to the said Court or its representative.
Further, I acknowledge and consent that a portion of any recovery, as directed by the court,
shall be paid to the clerk for reimbursement of all fees and costs incurred by me as a result of being
granted leave to proceed in forma pauperis.
(Signature of Applicant)
I understand that a false statement or answer to any question in this declaration will subject
me to penalties of perjury. I DECLARE UNDER PENALTY OF PERJURY UNDER THE
LAWS OF THE UNITED STATES OF AMERICA THAT THE FOREGOING IS TRUE AND
CORRECT. See 28 U.S.C. § 1746 and 18 U.S.C. § 1621.
(Inmate Prison Number)
I request that an authorized officer of the institution in which I am confined, or other
designated entity, such as Inmate Services for the Nevada Department of Prisons (NDOC), complete
the below Financial Certificate.
I understand that:
(1) if I commence a petition for writ of habeas corpus in federal court pursuant to 28 U.S.C.
§ 2254, the filing fee is $5.00, and that such fee will have to be paid by me if the court denies my
in forma pauperis application;
(2) if I commence a civil rights action in federal court pursuant to 42 U.S.C. § 1983, the
filing fee is $402.00 (which includes the $350 filing fee and a $52 administrative fee), which I
must pay in full; and
(a) if my current account balance (line #1 below) is $402.00 or more, I will not
qualify for in forma pauperis status and I must pay the full filing fee of $402.00 before I will be
allowed to proceed with the action;
(b) if I do NOT have $402.00 in my account as reflected on line #1 below, before
I will be allowed to proceed with an action I will be required to pay 20% of my average monthly
balance (line #2 below), or the average monthly deposits to my account (line #3 below), whichever
is greater, and thereafter I must pay installments of 20% of the preceding month’s deposits to my
account in months that my account balance exceeds $10.00 (if I am in the custody of the NDOC, I
hereby authorize the NDOC to make such deductions from deposits to my account, and I further
understand that if I have a prison job, then the 20% of my paycheck that is guaranteed to me as
spendable money will be sent to the court for payment of the filing fee); and
(c) I must continue to make installment payments until the $350.00 filing fee is fully
paid, without regard to whether my action is closed or my release from confinement. The $52
administrative fee will be waived only if I am granted permission to proceed in forma pauperis.
Type of action (check one):
INMATE NAME (printed)
SIGNATURE & PRISON NUMBER
-----------------------------1. CURRENT ACCOUNT BALANCE
2. AVERAGE MONTHLY BALANCE*
3. AVERAGE MONTHLY DEPOSITS*
4. FILING FEE (based on #1, #2 or #3, whichever is greater)
* for the past six (6) months, from all sources, including amount in any savings
account that is in excess of minimum amount that must be maintained
-----------------------------I hereby certify that as of this date, the above financial information is accurate for the above
(Please sign in ink in a)
(color other than black.)
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