PLAINTIFF/PETITIONER/MOVANT'S NAME PRISON NUMBER PLACE OF CONFINEMENT ADDRESS United States District Court Southern District Of California Civil No. , Plaintiff/Petitioner/Movant v. , Defendant/Respondent (TO BE FILLED IN BY U.S. DISTRICT COURT CLERK) MOTION AND DECLARATION UNDER PENALTY OF PERJURY IN SUPPORT OF MOTION TO PROCEED IN FORMA PAUPERIS I, declare that I am the Plaintiff/Petitioner/Movant in this case. In support of my request to proceed without prepayment of fees or security under 28 U.S.C. § 1915, I further declare I am unable to pay the fees of this proceeding or give security because of my poverty, and that I believe I am entitled to redress. In further support of this application, I answer the following question under penalty of perjury: 1. Are you currently incarcerated? G Yes G No (If "No" go to question 2) If "Yes," state the place of your incarceration Are you employed at the institution? G Yes G No Do you receive any payment from the institution? G Yes G No [Have the institution fill out the Certificate portion of this affidavit and attach a certified copy of the trust account statement from the institution of your incarceration showing at least the last six months transactions.] , CIV-67 (Rev. 2/05) I:\Everyone\1983\_IFP-form.wpd American LegalNet, Inc. www.FormsWorkFlow.com 2. Are you currently employed? G Yes G No a. If the answer is "Yes," state the amount of your take-home salary or wages and pay period and give the name and address of your employer. 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. 3. In the past twelve months have you received any money from any of the following sources?: a. Business, profession or other self-employment G Yes G No b. Rent payments, royalties interest or dividends G Yes G No c. Pensions, annuities or life insurance G Yes G No d. Disability or workers compensation G Yes G No e. Social Security, disability or other welfare G Yes G No e. Gifts or inheritances G Yes G No f. Spousal or child support G Yes G No g. Any other sources G Yes G No If the answer to any of the above is "Yes" describe each source and state the amount received and what you expect you will continue to receive each month. 4. Do you have any checking account(s)? a. Name(s) and address(es) of bank(s): b. Present balance in account(s): G Yes G No 5. Do you have any savings/IRA/money market/CDS' separate from checking accounts? a. Name(s) and address(es) of bank(s): b. Present balance in account(s): 6. Do you own an automobile or other motor vehicle? G Yes Year: Model: a. Make: b. Is it financed? G Yes G No c. If so, what is the amount owed? G No G Yes G No CIV-67 (Rev. 2/05) -2- I:\Everyone\1983\_IFP-form.wpd American LegalNet, Inc. www.FormsWorkFlow.com 7. Do you own any real estate, stocks, bonds, securities, other financial instruments, or other valuable property? G Yes G No If "Yes" describe the property and state its value. 8. 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. 9. List any other debts (current obligations, indicating amounts owed and to whom they are payable): 10. List any other assets or items of value (specify real estate, gifts, trusts inheritances, government bonds, stocks, savings certificates, notes, jewelry, artwork, or any other assets [include any items of value held in someone else's name]): 12. If you answered all of the items in #3 "No," and have not indicated any other assets or sources of income anywhere on this form, you must explain the sources of funds for your day-to-day expenses. I declare under penalty of perjury that the above information is true and correct and understand that a false statement herein may result in the dismissal of my claims. DATE SIGNATURE OF APPLICANT CIV-67 (Rev. 2/05) -3- I:\Everyone\1983\_IFP-form.wpd American LegalNet, Inc. www.FormsWorkFlow.com If you are a prisoner you must have an officer from your institution provide this official certificate as to the amount of money in your prison account. There are no exceptions to this requirement. PRISON CERTIFICATE (Incarcerated applicants only) (To be completed by the institution of incarceration) I certify that the applicant (NAME OF INMATE) , , (INMATE'S CDC NUMBER) has the sum of $ on account to his/her credit at . (NAME OF INSTITUTION) I further certify that the applicant has the following securities to his/her credit according to the records of the aforementioned institution. I further certify that during the past six months the applicant's average monthly balance was $ and the average monthly deposits to the applicant's account was $ , . ALL PRISONERS MUST ATTACH A CERTIFIED COPY OF THEIR TRUST ACCOUNT STATEMENT SHOWING TRANSACTIONS FOR THE SIX-MONTH PERIOD IMMEDIATELY PRECEDING THE FILING OF THE COMPLAINT PER 28 U.S.C. § 1915(a)(2). DATE SIGNATURE OF AUTHORIZED OFFICER OF INSTITUTION OFFICER'S FULL NAME (PRINTED) OFFICER'S TITLE/RANK CIV-67 (Rev. 2/05) -4- I:\Everyone\1983\_IFP-form.wpd American LegalNet, Inc. www.FormsWorkFlow.com TRUST ACCOUNT WITHDRAWAL AUTHORIZATION (Incarcerated applicants only) (This form MUST be completed by the prisoner requesting to proceed in forma pauperis. An incomplete "Trust Account Withdrawal Authorization Form," or "Prison Certificate" will result in automatic denial of the prisoner's request to proceed in forma pauperis.) I, ___________________________________________, request and authorize the agency holding me in (Name of Prisoner/ CDC No.) custody to prepare for the Clerk of the United States District Court for the Southern District of California, a certified copy of the statement for the past six months of my trust fund account (or institutional equivalent) activity at the institution where I am incarcerated. I further request and authorize the agency holding me in custody to calculate and disburse funds from my trust fund account (or institutional equivalent) pursuant to any future orders issued by the Court relating to this civil action pursuant to the Prison Litigation Reform Act of 1995, Pub. L. No. 104-134, Title VIII, §§ 801-10, 110 Stat. 1321 (1996). This authorization is furnished in connection with a civil action filed in the Southern District of California, and I understand that, pursuant to 28 U.S.C. §§ 1914 and 1915(b)(1), the total amount of filing fees for which I am