Name and Prisoner/Booking NumberPlace of ConfinementMailing AddressCity, State, Zip CodeIN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ARIZONA) , )Petitioner,) CASE NO. )vs.))APPLICATION TO PROCEEDIN FORMA PAUPERIS, )Respondent(s).)BY A PRISONER)(HABEAS)I,, declare, in support of my request to proceed in the aboveentitled case without prepayment of fees under 28 U.S.C. § 1915, that I am unable to pay the fees for these proceedings or to give security therefor and that I believe I am entitled to relief.In support of this application, I answer the following questions under penalty of perjury:1.Are you currently employed at the institution where you are confined?NoYesIf "Yes," state the amount of your pay and where you work.2.Do you receive any other payments from the institution where you are confined?NoYesIf "Yes," state the source and amount of the payments.98-ifphab Revised 6/9812001 © American LegalNet, Inc.3.Do you have any other sources of income, savings, or assets either inside or outside of the institution where you are confined?YesNoIf "Yes," state the sources and amounts of the income, savings, or assets.I declare under penalty of perjury that the above information is true and correct.DATESIGNATURE OF APPLICANTCERTIFICATE OF CORRECTIONAL OFFICIAL AS TO STATUS OF APPLICANT'S TRUST ACCOUNTI,, certify that as of the date applicant signed this application:(Printed name of official)The applicant's trust account balance at this institution is: $.DATEAUTHORIZED SIGNATUREINSTITUTIONTITLE/ID NUMBER22001 © American LegalNet, Inc.