Free application.PDF - Arizona

Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
) , ) ) CASE NO. ) ) ) APPLICATION TO PROCEED , ) IN FORMA PAUPERIS ) BY A PRISONER ) (HABEAS)

Petitioner, vs. Respondent(s).

I, , declare, in support of my request to proceed in the above entitled case without prepayment of fees under 28 U.S.C. § 1915, that I am unable to pay the fees for these proceedings or to give security therefor and that I believe I am entitled to relief. In support of this application, I answer the following questions under penalty of perjury: 1. Are you currently employed at the institution where you are confined? If "Yes," state the amount of your pay and where you work.

GYes

GNo

2.

Do you receive any other payments from the institution where you are confined? If "Yes," state the source and amount of the payments.

GYes

GNo

98-ifphab Revised 6/98

1

3.

Do you have any other sources of income, savings, or assets either inside or outside of the institution where you are confined? GYes GNo If "Yes," state the sources and amounts of the income, savings, or assets.

I declare under penalty of perjury that the above information is true and correct.

DATE

SIGNATURE OF APPLICANT

CERTIFICATE OF CORRECTIONAL OFFICIAL AS TO STATUS OF APPLICANT'S TRUST ACCOUNT I, (Printed name of official) The applicant's trust account balance at this institution is: $ . , certify that as of the date applicant signed this application:

DATE

AUTHORIZED SIGNATURE

TITLE/ID NUMBER

INSTITUTION

2