UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA INSTRUCTIONS FOR FILING AN APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER UNDER 28 U.S.C. § 1915 You must submit to the court a completed Prisoner's Application to Proceed In Forma Pauperis if you are unable to pay the entire filing fee at the time you file your complaint or petition. Your application must include copies of the prisoner trust account statement showing transactions for the last six months and a certificate of funds in prisoner's account, signed by an authorized officer of the institution. A. Non-habeas Civil Actions The fee for filing any civil action other than a petition for a writ of habeas corpus is $400.00 ($350 filing fee plus $50 administrative fee). Even if you are granted leave to proceed in forma pauperis, you must still pay the $350 filing fee (not the $50 administrative fee), but the filing fee will be paid in several installments. 28 U.S.C. § 1915. You must pay an initial partial filing fee of 20 percent of the greater of (a) the average monthly deposits to your account for the 6-month period immediately before the complaint was filed or (b) the average monthly balance in your account for the 6-month period immediately before the complaint was filed. The court will use the information provided on the certificate of funds and the trust account statement to determine the filing fee immediately due and will send instructions to you and the prison trust account office for payment if in forma pauperis status is granted. After the initial partial filing fee is paid, your prison's trust account office will forward to the court each month 20 percent of the most recent month's income to your prison trust account, to the extent the account balance exceeds ten dollars ($10). Monthly payments will be required until the full filing fee is paid. If you have no funds over ten dollars ($10) in your account, you will not be required to pay part of the filing fee that month. If your application to proceed in forma pauperis is granted, you will be liable for the full $350 filing fee even if your civil action is dismissed. That means the court will continue to collect payments until the entire filing fee is paid. B. Habeas Actions The fee for filing a petition for a writ of habeas corpus is $5 ($5 filing fee plus $0 administrative fee). If you are granted leave to proceed in forma pauperis, you will not be required to pay any portion of this fee. If you are not granted leave to proceed in forma pauperis, you must pay the fee in one payment and not in installments. If you use a habeas form to file a non-habeas civil action, you will be required to pay the fee applicable to all non-habeas civil actions. FILING INSTRUCTIONS, PRISONER IFP (rev. 8/2015) page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA Plaintiff, vs. Defendant. ) ) ) ) ) ) ) ) ) ) ) CASE NO. PRISONER'S APPLICATION TO PROCEED IN FORMA PAUPERIS I, , declare under penalty of perjury that I am the plaintiff in the above entitled case and that the information I offer throughout this application is true and correct. I offer this application in support of my request to proceed without being required to prepay the full amount of fees and costs or give security. I state that because of my poverty I am unable to pay the costs of this action or give security, and that I believe that I am entitled to relief. IN SUPPORT OF THIS APPLICATION, I PROVIDE THE FOLLOWING INFORMATION: 1. Are you presently employed? YES G NO G If your answer is "yes," state both your gross and net salary or wages per month, and give the name and address of your employer: Gross: Employer (name and address): Net: If the answer is "no," state the date of last employment and the amount of the gross and net salary and wages per month which you received. (If you are imprisoned, specify the last place of employment prior to imprisonment.) 1 American LegalNet, Inc. www.FormsWorkFlow.com 2. Have you received, within the past twelve (12) months, any money from any of the following sources: a. b. c. d. e. Business, profession or self employment? Income from stocks, bonds or royalties? Rent payments? Pensions, annuities or life insurance payments? Federal or state welfare payments, Social Security or other government source? YES G YES G YES G YES G YES G NO G NO G NO G NO G NO G If the answer is "yes" to any of the above, describe each source of money and state the amount received from each. 3. Are you married? YES G NO G Spouse's Full Name: Spouse's Place of Employment: Spouse's Monthly Salary, Wages or Income: Gross $ 4. a. b. Net $ List amount you contribute to your spouse's support: $ List the persons other than your spouse who are dependent upon you for support and indicate how much you contribute toward their support. (NOTE: For minor children, list only their initials and ages. Do not include their names.) 5. Do you own or are you buying a home? YES G NO G Estimated Market Value: $ 6. Make Is it financed? Yes Monthly Payment: $ No Do you own an automobile? Year Amount of Mortgage: $ YES G Model If so, Total Due: $ NO G 2 American LegalNet, Inc. www.FormsWorkFlow.com 7. Do you have a bank account? YES G NO G Name(s) and address(es) of bank (do not include account numbers): Present balance(s): $ Do you own any cash? Do you have any other assets? YES G YES G NO G NO G Amount: $ If "yes," provide a description of each asset and its estimated market value. 8. What are your monthly expenses? Utilities: Clothing: YES G NO G Rent: $ Food: $ 9. Do you have any charge accounts/credit cards? If yes, list them below. (Do not include account numbers.) Name of Account $ $ $ 10. Monthly Payment Total Owed on This Acct. $ $ $ Do you have any other debts? (List current obligations, indicating amounts and to whom they are payable. Do not include account numbers.) 11. Does the complaint you are seeking to file raise claims that have been presented in other lawsuits? YES G NO G If so, please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in which they were filed. 3 American LegalNet, Inc. www.FormsWorkFlow.com I consent to prison officials withdrawing from my trust account and paying to the court the initial partial filing fee and all installment payments required by the court. I declare under the penalty of perjury that the foregoing is true and correct and understand that a false statement