Free Prisoner Motion for Leave to Proceed in Forma Pauperis - Connecticut

UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT

PRISONER'S APPLICATION

TO

PROCEED

IN

FORMA PAUPERIS

IN A

CIVIL RIGHTS ACTION

ATTACH THIS FORM TO YOUR COMPLAINT

_____________________________ : [Your name] : Plaintiff,: : vs. : _____________________________ : _____________________________ : _____________________________ : _____________________________ : [People you are suing] : Defendant(s):

PRISONER NO: _____cv______( ) [Leave blank for Clerk]

I, ___________________________________________, [your name] state that, because of my poverty, I am unable to pay the filing fee for the above-captioned lawsuit at the time that I file my complaint. I therefore request permission to file my complaint without pre-payment of the filing fee and to proceed in forma pauperis (as a poor person). I understand that I cannot file for free. I realize that even

if the Court allows me to proceed in forma pauperis I will have to pay the full filing fee of $350 through installments deducted from my inmate trust fund. I also understand that the Department of Correction Inmate Trust Fund will continue to deduct money from my
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inmate trust fund to pay the filing fee to the Court even if my lawsuit is dismissed. I also understand that I must support my claim of poverty by truthfully answering all of the following questions and by I obtaining a signed certification of the balance on my inmate trust fund from the DOC Inmate Trust Fund or my prison counselor. realize that I may be prosecuted for perjury if I lie on this application, and that perjury is punishable by imprisonment for up to five years and/or a fine of $250,000 (18 U.S.C. §§ 1621, 3571). WARNING: You MUST complete EVERY section or your application will be denied. Answer every question truthfully and accurately. 1. 2. 3. 4. 5. Full Name: _____________________________________________

Inmate Number: _____________________________________________ Correctional Institution:___________________________________ Are you currently employed? (Yes or No) ______ If you are currently employed, state your job title and the amount you get paid each month: Job: _________________________________________ Monthly wages: $________

6. a. b. c. d. e. d. e.

Within the past twelve (12) months, how much money have you received from the following sources? [If none, write "zero"] Employment: Type __________________________ $_________ Rent someone paid you: $____________ Interest on savings: $___________ Dividends on investments: $___________ Pension, annuity, or life insurance: $___________ Gifts or inheritances: $___________ Other sources: Type __________________________ $______ TURN OVER

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7.

How much money do you have in cash, or in checking or savings accounts, including your inmate trust account? [If none, write "zero"] $__________

8.

What is the total value of property you own excluding ordinary household furnishings and clothing, but including automobiles, real estate, stocks, bonds, and notes? [If none, write "zero"] $_______________

9.

How much money do you contribute each month to the support of family members or other individuals? Provide the name of each person you support and the relationship between you (e.g., husband, wife, domestic partner, child, or grandparent). [If you need more space, attach an additional page.] a. b. c. Name & Relationship:____________________________$_____ Name & Relationship:____________________________$_____ Name & Relationship:____________________________$_____

DECLARATION UNDER PENALTY OF PERJURY WARNING: You MUST sign this section or your application for IFP status will be denied

I, ____________________________________, the applicant, declare under penalty of perjury that the information I have provided in this application is true and correct.

Signed: Dated:

____________________________________ _____________________________, 20___

WARNING: You have not finished. section.

You MUST complete the next

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PRISONER AUTHORIZATION WARNING: You MUST complete and sign this section and then show this page to the Inmate Trust Fund Department or your prison counselor so that they can sign the next section. Your name: Your inmate number: DOC facility where you are detained: Case Number [leave blank for Clerk]: Filing Date [leave blank for Clerk]: I, _______________________________________, the applicant, understand that even if my request for In Forma Pauperis status is granted, Congress has said that I must pay the full filing fee of $350, which will be deducted in installments from my inmate trust fund. I further understand that the deductions from my inmate trust fund will continue until the full fee is paid, even if my case is dismissed before then. I authorize the Department of Correction Inmate Trust Fund to: (1) certify on the next page of this application the current and average balance over the last six months for my inmate trust fund; (2) send the Court copies of my trust fund statement for the past six months; (3) obtain funds to cover the $350 filing fee by deducting installment payments from my inmate trust fund based on the average of deposits to or balance in my inmate trust fund, in accordance with 28 U.S.C. Section 1915; (4) send the $350 payment for the filing fee to the Court.

Signed: Date:

________________________________ [Your signature] _________________________, 20___ [Today's date]

WARNING: You have not finished. You MUST show this page to the Inmate Trust Fund Department or your prison counselor so that they can sign the next section. Do NOT send this application to the Court without the signature of the Inmate Trust Fund Department or your prison counselor on the next page.

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CERTIFICATION OF INMATE ACCOUNT BALANCE

WARNING: You MUST show this application to the Inmate Trust Fund Department or your prison counselor so that they can read page 4 and sign this section.

Your name: Your inmate number: DOC facility where you are detained: I, _______________________________________, counselor / employee of the Connecticut Department of Correction Inmate Trust Fund, certify that the applicant named herein has the sum of $________ on account. I further certify that, according to the records of the institution, the applicant's average balance for the last six months was $___________ and the average monthly deposits during the same period were $__________. A certified copy of the applicant's trust fund statement for the last six (6) months is attached.

Signed: Name & Rank: Date:

__________________________________ (Inmate Trust Fund Officer or Prison Counselor) __________________________________ ___________________________, 20___

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CHECKLIST FOR IFP APPLICATION

NOTE:

Before you send this application to the Court you MUST:

_______ _______ _______

Sign the Declaration under Penalty of Perjury on p. 3 Sign the Prisoner Authorization on p. 4 Show the application to the Inmate Trust Fund Department or your prison counselor and have them sign p. 5 Answer every question truthfully and accurately

_______

When the Inmate Trust Fund Department or your counselor has signed page 5, attach this form to your complaint and send it to the Court on one of the addresses provided on the complaint form.

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