Tryon v. State of Washington DOC

Filing 6

ORDER granting petitioner's 5 Letter/Motion for Relief from Court's Order; directing Clerk to reopen petitioner's case, signed by Judge Robert S. Lasnik. (Attachments: # 1 Deficiency Letter, # 2 IFP Application)**5 PAGE(S), PRINT ALL**(Tamara Tryon, Prisoner ID: 367756)(SWT)

WAWD (Rev. 12/11) Habeas IFP

UNITED STATES DISTRICT COURT
Western District of Washington
Case Number: 17-cv-589-RSL-JPD

DECLARATION AND APPLICATION
TO PROCEED IN FORMA PAUPERIS
IN A FEDERAL HABEAS ACTION

Petitioner
vs.

DO NOT use this form if you are bringing a
civil action.
Respondent(s)

DECLARATION AND APPLICATION TO PROCEED IN FORMA PAUPERIS
I (print your name)

declare I am the petitioner in this habeas
proceeding; I believe I am entitled to relief; and I am unable to pay the costs of this proceeding or give
security thereof.
This action proceeds pursuant to: 28 U.S.C.

§2241

§2254

§2255

In support of this application, I answer all of the following questions:
1. Are you presently employed?
Yes

Total amount of net monthly salary (take home pay) $
Name and address of employer

No

Date of last employment
Amount of net monthly salary when last employed

$

2. For the past twelve months, list the amount of money you have received from any of the following sources.
a. Business, profession or other self-employment
b.
c.
d.
e.
f.

Income from rent, interest or dividends
Pensions, annuities or life insurance payments
Disability, unemployment, workers compensation or public assistance
Gifts or inheritances
Money received from child support or alimony

g. Describe any other source of income

Page of

$
$
$
$
$
$
$

3. List the amount for each of the following (include prison account funds) :
Cash on hand $

Checking Account $

Savings Account $

4. Do you own or have any interest in any real estate, stocks, bonds, notes, retirement plans, automobiles, or
other valuable property (excluding ordinary household furnishings and clothing)?
If Yes, describe the property and state its approximate value:
Yes
$
No
5. Are any persons dependent upon you for support? If Yes, state their relationship to you, and indicate how
much you contribute toward their support each month. (Do not include names of minor children. )
Yes
$
No
6. Describe the types of monthly expenses you incur, such as housing, transportation, utilities, loan payments,
or other regular monthly expenses and the amount spent each month.

$

7. Provide any other information that will help explain why you cannot pay court fees and costs.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on: (Date)

Signature of Applicant
CERTIFICATION

Have the institution fill out the Certification portion of this application and attach a certified copy
of your prison trust account statement showing transactions for the past six months.
I certify that the applicant named herein has the sum of $
(Name of Institution)

Executed on: (Date)

Signature of Financial Officer
Page of

on account to his/her credit at