UNITED STATES DISTRICT COURT DISTRICT OF OREGON Plaintiff, APPLICATION TO PROCEED IN FORMA PAUPERIS v. CASE NUMBER: Defendant. 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. § 1915, I declare than I 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: 1. Are you currently incarcerated: ~ Yes ~ No If "Yes" state the place of your incarceration. ___________________________________ If "Yes" have the institution fill out the Certificate portion of this application and attach a certified copy of your prison trust account showing transactions for the past six months. 2. Are you currently employed? ~ Yes ~ No a. b. 3. If the answer is "Yes" state the amount of your pay. 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. ______________________________________________________ In the past twelve months have you received any money from any of the following sources? a. b. c. d. e. f. Business, profession or other self-employment Rent payments, interest, or dividends Pensions, annuities, or life insurance payments Disability or workers compensation payments Gifts or inheritances Any other sources ~ ~ ~ ~ ~ ~ Yes Yes Yes Yes Yes Yes ~ ~ ~ ~ ~ ~ No No No No No No If the answer to any of the above is "Yes" describe by that item each source of money and state the Revised April 24, 2008 Page 1 Prisoner IFP Application USDC - Oregon American LegalNet, Inc. www.FormsWorkFlow.com amount received and what you expect you will continue to receive. Please attach an additional sheet if necessary. 4. Do you have cash or checking or savings accounts, (including prison trust accounts)? ~ Yes ~ No If "Yes" state the total amount: __________________ 5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other valuable property? ~ Yes ~ No If "Yes" list the asset(s) and state the value of each asset listed. 6. Do you have any other assets? ~ Yes ~ No If "Yes" list the asset(s) and state the value of each asset listed. 7. List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support. 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 toward the full filing fee of $350.00 for a prisoner civil rights complaint in accordance with 28 U.S.C. § 1915(b). I declare under penalty of perjury that the above information is true and correct. ____________________ DATE Revised April 24, 2008 Page 2 ________________________________________________ SIGNATURE OF APPLICANT Prisoner IFP Application USDC - Oregon American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE (To be completed by the institution of incarceration.) I certify that the applicant named herein 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 of monthly deposits to the applicant's account was $_________. I have attached a certified copy of the applicant's trust account statement showing the transactions for the past six months. ____________________ DATE Revised April 24, 2008 Page 3 ________________________________________________ SIGNATURE OF AUTHORIZED OFFICER Prisoner IFP Application USDC - Oregon American LegalNet, Inc. www.FormsWorkFlow.com