APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER
I, , declare that I am the plaintiff in the above-entitled proceeding; that, in support of my request to proceed without prepayment of fees under 28 U.S.C. section 1915, I declare am unable to pay the fees for these proceedings or give security therefor and that I am entitled to the relief sought in the complaint.
In support of this application, I answer the following questions under penalty of perjury: Are you currently incarcerated? Yes No (If "no" DO NOT USE THIS FORM) State the place of your incarceration.
Are you currently employed (includes prison employment)?
Yes No a. If the answer is "yes" state the amount of your pay.
b. If the answer is "no" state the date of your last employment, the amount of your take-home salary or wages and pay period, and the name and address of your last employer.
Have you received any money from the following sources over the last twelve months?
a. Business, profession, or other self-employment: Yes No
b. Rent payments, interest or dividends: Yes No
c. Pensions, annuities or life insurance payments: Yes No
d. Disability or workers compensation payments: Yes No
e.. Gifts or inheritances: Yes No
f. Any other sources: Yes No If the answer to any of the above is "yes," describe by that item each source of money. Also state the amount received and what you expect you will continue to receive (attach an additional sheet if necessary).
Do you have cash (includes balance of checking or savings accounts)? Yes No If "yes" state the total amount:
Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other valuable property? Yes No If "yes" ...