UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA CASE NUMBER PRISONER/PLAINTIFF, v. DEFENDANT(S). REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT , declare under penalty of perjury, that the following is I, true and correct; that I am the prisoner-plaintiff in the above entitled case; that in support of my request to proceed without prepayment of fees under 28 U.S.C. Section 1915, I declare that because of my poverty I am unable to pay the full costs of said proceedings or to give security therefore and that I am entitled to redress. I further declare under penalty of perjury that the responses which I have made to the questions and instructions below are true, correct and complete. 1. Are you presently employed in prison? GYes GNo a. If the answer is yes, state the number of hours you work per week and the hourly rate of pay: b. State the place of your incarceration Have the institution fill out the Certificate portion of this application and attach a certified copy of your prison trust account statement showing transactions for the past six months. 2. Have you received, within the past twelve months, any money from any of the following sources? a. Business, profession or form of self-employment? GYes GNo b. Rent payments, interest or dividends? GYes GNo c. Pensions, annuities or life insurance payments? GYes GNo d. Gifts or inheritances? GYes GNo e. Any other income (other than listed above)? GYes GNo f. Loans? GYes GNo If the answer to any of the above is yes, describe such source of money and state the amount received from each source during the past twelve (12) months: . REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT CV-60P (04/06) Page 1 of 3 American LegalNet, Inc. www.USCourtForms.com 3. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison accounts, if applicable.) G Yes G No If the answer is yes, identify each account and separately state the amount of money held in each account for each of the six (6) months prior to the date of this declaration. 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? G Yes G No If the answer is yes, describe the property and state it approximate value: 5. In what year did you last file an Income Tax Return? Approximately how much income did your last tax return reflect? 6. List the persons who are dependent upon your for support, state your relationship to those persons, and indicate how much you contribute toward their support: I understand that a false statement or answer to any question in this declaration will subject me to penalties for perjury. I further understand that perjury is punishable by a term of imprisonment of up to five (5) years and/or a fine of $250,000 (18 U.S.C. Sections 1621, 3571). State County (or City) I, , declare under penalty of perjury that the foregoing is true and correct. Date Prisoner/Plaintiff (Signature) REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT CV-60P (04/06) Page 2 of 3 American LegalNet, Inc. www.USCourtForms.com PRISONER AUTHORIZATION If my request to proceed without prepayment of filing fees is granted, I understand that I am required by statue to pay the full amount of the filing fees for this case, regardless of my forma pauperis status and the disposition of this case. I further authorize the prison officials at this institution to assess, collect and forward to the Court the full amount of these fees, in monthly payments based on the average of deposits to or balance in my prison trust account in accordance with 28 U.S.C. Section 1915. Prisoner-Plaintiff (Signature) CERTIFICATE OF AUTHORIZED OFFICER on account at I hereby certify that the Prisoner-Plaintiff herein has credit in the sum of $ institution where Prisoner-Plaintiff is confined. the I further certify that during the past six months the applicant's average monthly balance was $ certify that during the past six months the average of monthly deposits to the applicant's account was$ A certified copy of the prisoner-plaintiff's trust account statement for the last six (6) months is attached. . I further . Date Authorized Officer of Institution (Signature) REQUEST TO PROCEED WITHOUT PREPAYMENT OF FILING FEES WITH DECLARATION IN SUPPORT CV-60P (04/06) Page 3 of 3 American LegalNet, Inc. www.USCourtForms.com