Free Application to Proceed - Oregon

UNITED STATES DISTRICT COURT DISTRICT OF OREGON

Plaintiff, v. APPLICATION TO PROCEED IN FORMA PAUPERIS 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 that I am unable to pay the fees for this proceeding 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: 9 Yes 9 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? a. b. 9 Yes 9No

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 takehome 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. 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 9Yes 9Yes 9Yes 9Yes 9Yes 9Yes 9No 9No 9No 9No 9No 9No

If the answer to any of the above is "Yes" describe by that item each source of money and state the amount received and what you expect you will continue to receive. Please attach an additional sheet if necessary.

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Application for IFP

4.

Do you have cash or checking or savings accounts, (including prison trust accounts)?

9Yes

9No

5.

If "Yes" state the total amount: __________________ Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other valuable property? 9Yes 9No If "Yes" list the asset(s) and state the value of each asset listed.

6.

Do you have any other assets? If "Yes" list the asset(s) and state the value of each asset listed.

9Yes

9No

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 the Prison Litigation Reform Act, P.L. 104-134 (110 Stat. 1321), Section 804(a) (to be codified at 28 U.S.C. § 1915(b)). I declare under penalty of perjury that the above information is true and correct. ____________________ DATE ________________________________________________ SIGNATURE OF APPLICANT

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

_______________________________________________ SIGNATURE OF AUTHORIZED OFFICER

Revised April 6, 2006 Page 2

Application for IFP