Goodrum v. Woodman et al

Filing 4

ORDER - The Clerk shall SEND Plaintiff a copy of the instructions and application to proceed IFP for an inmate at Northern Nevada Correctional Center. Plaintiff has 30 days from the date of this Order to either pay the full $405 filing fee or file a fully completed IFP application. Signed by Magistrate Judge Craig S. Denney on 5/8/2024. (For Distribution by law library.) (Attachments: # 1 IFP Form w instructions (NNCC))(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 UNDER 28 U.S.C. § 1915
BY AN INMATE AT NORTHERN NEVADA CORRECTIONAL CENTER
Please use the attached form if you are an inmate housed at Northern Nevada Correctional
Center. 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.
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 in Section A. If you are filing a petition for writ of
habeas corpus, please follow the instructions in Section B. If you are an inmate in the custody of
the Nevada Department of Corrections (NDOC), please follow the instructions in Section C. If
you are an inmate not in NDOC custody, please follow the instructions in Section D. To submit
your application, please follow the instructions in Section E.
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.”
A.

Non-Habeas Civil Actions

The fee for filing any civil action other than a petition for writ of habeas corpus is $405
(which includes the $350 filing fee and the $55 administrative fee). If you are granted leave to
proceed in forma pauperis, you must still pay the $350 filing fee (but not the $55 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.
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.
B.

Habeas Actions

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
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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.
C.

Inmates in NDOC Custody

If you are in NDOC custody, you must sign the financial acknowledgement on page 3 of
the application. After receiving your acknowledgement, the court will order NDOC to file your
inmate trust fund account statement directly with the court. The court will use that information to
determine the filing fee immediately due and will send instructions to you and NDOC Inmate
Banking for payment if in forma pauperis status is granted. If you disagree with the inmate trust
fund account statement filed by NDOC, you will need to resolve those disputes with NDOC.
D.

Inmates not in NDOC Custody

If you are not in NDOC custody, you must sign the financial acknowledgement on page 3
of the application, have an authorized officer at the institution you are incarcerated at complete the
certificate on page 4 of the application, and attach a certified copy of your trust fund account
statement showing transactions for the past six months.
E.

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.
If your facility files cases with the U.S. District Court electronically, provide the
application and your complaint or petition to the Law Library for filing.
If your facility does not file cases electronically, mail the application and your complaint
or petition to the U.S. District Court in Las Vegas or Reno:

U.S. District Court Office of the Clerk
333 Las Vegas Blvd., South, Room #1334
Las Vegas, NV 89101

OR

U.S. District Court Office of the Clerk
400 S. Virginia Street, Room #301
Reno, NV 89501

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 will determine
which unofficial division to file the case when assigning the case number.
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UNITED STATES DISTRICT COURT
DISTRICT OF NEVADA
__________________________________
Plaintiff/Petitioner,

APPLICATION TO PROCEED
IN FORMA PAUPERIS
BY AN INMATE AT NORTHERN
NEVADA CORRECTIONAL
CENTER

v.
Case Number:
__________________________________
Defendant/Respondent.

I, _____________________________, declare that I am the (check the appropriate box)
Plaintiff (filing 42 U.S.C. § 1983)
Petitioner (filing petition for writ of habeas corpus, 28 U.S.C. §§ 2254 or 2241)
Movant (filing 28 U.S.C. § 2255 motion)
Other
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 declare under penalty of perjury, see 28 U.S.C. §
1746 and 18 U.S.C. § 1621, that the following answers are true and correct.
1. Are you currently incarcerated? ___ Yes

___ No (if “no” do not use this form)

a. Where are you currently incarcerated (name of prison/jail)?
___________________________________________________________
b. What is your prison/jail identification number? _____________________
2. Are you currently employed (includes prison employment)? ___ Yes

___ No

a. If “yes,” state the amount of your pay and your employer.
___________________________________________________________
b. If “no,” state the date of your last employment and the amount of pay per month
you received. ________________________________________________

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3. Have you received any money from the following sources over the last 12 months?
a.

Business, profession, or other form of self-employment?

___ Yes

___ No

b.

Rent payments, interest, or dividends?

___ Yes

___ No

c.

Pensions, annuities, or life insurance payments?

___ Yes

___ No

d.

Gifts or inheritances?

___ Yes

___ No

e.

Disability or social security payments?

___ Yes

___ No

f.

Any other sources?

___ Yes

___ No

If the answer to any of the above is “yes,” describe each source of money, state the
amount received, and what you expect you will continue to receive.

4. Do you have cash (including balance of checking or savings accounts outside of
prison/jail and any funds in prison/jail accounts)? ___ Yes
___ No
a. If “yes,” state the amount (do not include your account numbers):
_______________________________________________________________
5. Do you own or have any interest in any real estate, stocks, bonds, securities, trusts, other
financial instruments, automobiles, or other valuable property (excluding ordinary
household furnishings and clothing)?
___ Yes
___ No
a. If “yes,” describe the property and state the value: _______________________
6. Have you placed any property, assets, or money in the name or custody of anyone else in
the last two years?
___ Yes
___ No
a. If “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.
________________________________________________________________
________________________________________________________________
7. List the people who are dependent upon you for support, state your relationship to those
people, and indicate how much you contribute toward their support each month.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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FINANCIAL ACKNOWLEDGEMENT
This form must be dated and signed below for the court to consider your
application.
I hereby authorize the agency having custody of me to file with this court a copy of my
trust fund account statement for activity covering the last six months. Additionally, once
eligibility is established, I further authorize the agency having custody of me to collect from my
trust fund account and forward to the Clerk of the United States District Court payments in
accordance with 28 U.S.C. § 1915(b).
I understand that:
1. If I commence a petition for writ of habeas corpus in federal court pursuant to 28
U.S.C. § 2254 or 2241, the filing fee is $5.00, and 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 $405.00 (which includes the $350.00 filing fee and a $55.00
administrative fee), which I must pay in full. If the court denies my in forma
pauperis application, I must pay the full filing fee of $405.00 before I will be allowed
to proceed with the action.
3. If I do NOT have $405.00 in my inmate trust fund account, before I will be allowed
to proceed with an action, I will be required to pay 20% of my average monthly
balance, or the average monthly deposits to my account, 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.
4. I must continue to make installment payments until the $350.00 filing fee is fully
paid, even if my action is closed or I am released from confinement. The $55.00
administrative fee will be waived only if I am granted permission to proceed in forma
pauperis.
Applicant’s Signature:

Prison/Jail Number:

________________________________________________

_____________________

Date:
_____________________

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Inmates NOT in NDOC custody must complete certification below:
CERTIFICATE
(To be completed by an authorized officer of the institution of incarceration)
I certify that the applicant, _________________________________________________,
has the sum of $______________ on account to his/her credit at __________________________
(name of institution). I further certify that, during the past six months, the applicant’s average
monthly balance was $______________. I further certify that during the past six months the
average monthly deposits to the applicant’s account was $ _______________.
Please attach a certified copy of the applicant’s trust fund account statement showing
transactions for the past six months.

______________________________________________________
Signature of Authorized Officer

___________________
Date

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