UNITED STATES DISTRICT COURT EASTERN DISTRICT OF CALIFORNIA FRESNO DIVISION
July 29, 2008
RANDALL L. RADDIGAN, PLAINTIFF,
G. MILLER, ET AL, DEFENDANTS.
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" describe the property and state its value:
Do you have any other assets? Yes No If "yes," list the asset(s) and state the value of each asset listed:
List all persons dependent on you for support, stating your relationship to each person listed and how much you contribute to their support.
IMPORTANT: This form must be dated and signed below in order for the court to consider your application.
I hereby authorize the agency having custody of me to collect from my trust account and forward to the Clerk of the United States District Court payments in accordance with 28 U.S.C. section 1915(b)(2).
DATE SIGNATURE OF APPLICANT
NOTE: Within sixty days from the date of this application you must forward to the court a certified copy of your prison trust account statement showing transactions for the past six months.
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