Free MOTION TO PROCEED IN FORMA PAUPERIS - To be used by prisoners - Florida

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA DIVISION

, Inmate # Plaintiff/Petitioner, vs. , , . Defendant(s)/Respondent(s). / MOTION TO PROCEED IN FORMA PAUPERIS
I, , plaintiff/petitioner in the above-entitled action, move to proceed in forma pauperis pursuant to 28 U.S.C. § 1915 in the above-entitled action. I am unable to make full prepayment of fees or to give security therefore, and it is my belief that I am entitled to relief. I have not divested myself of any property, monies, or any items of value for the purpose of avoiding payment of said fees.

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CASE NO:

Signature of Plaintiff/Petitioner AFFIDAVIT IN SUPPORT OF MOTION TO PROCEED IN FORMA PAUPERIS (THIS AFFIDAVIT MUST BE COMPLETED IN ITS ENTIRETY) In support of this motion, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? Yes ( ) No ( )

If yes, place of incarceration: If not incarcerated, skip to Question #5.

2. 3. 4. 5.

Have you been incarcerated for at least six (6) months:

Yes (

)

No (

)

Have you been confined in the facility listed above (question #1) for the six months preceding the filing of this case? Yes ( ) No ( ) If not, where else have you been held: Are you presently employed? a. b. If yes, amount of salary or wages: If no, date of last employment: Yes ( ) when: No ( ) -

Employer: Salary:

6.

Have you received any money from any of the following sources within the past 12 months: a. b. c. d. e. Business, profession, or self-employment? Payments from rent, interest, or dividends? Pensions, annuities, or life insurance payments? Yes ( Disability or worker's compensation payments? Gifts, inheritances, or any other sources? Yes ( Yes ( ) Yes ( Yes ( Yes ( ) ) No ( ) ) ) ) No ( No ( No ( ) ) ) No ( No ( ) )

7.

Do you have any money in a checking or savings account?

If yes, state the total amount (including money in prison bank account): 8. Do you own any real estate, stocks, bonds, notes, automobiles, boats, or other valuable property (excluding ordinary household furnishings and clothing)? Yes ( ) No ( ) If yes, describe the property and its approximate value: 9. List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support:

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

SIGNATURE OF PLAINTIFF

DATE

- Attach Inmate Bank Account Printouts to this Motion -

Revised 07/02

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IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA DIVISION

, Inmate # Plaintiff/Petitioner vs. , , . Defendant(s)/Respondent(s). / .

CASE NO:

PRISONER CONSENT FORM AND FINANCIAL CERTIFICATE
I, , plaintiff/pe titioner in the ab ove-entitled action , understand that:

1. If I subm it a petition for writ of habeas corpus in this court, the filing fee is $5.00. I must pay such fee if my current prison ac cou nt balance, m y average account balance, or the average of m y m onthly deposits is $25.00 or m ore. I m ust re quest an authorized official to com plete the attached Financial Certificate and I must attach a print-out reflecting all transactions in my inmate bank account for the fu ll six (6) m onth period of tim e prec eding the filing of this com plaint. [See p arag raph 2(a)]. 2. If I submit a civil rights complaint or other civil action, the filing fee is $350.00. If my current account balance is m ore th an $ 400 .00, I will not qualify for in form a pauperis status. I must pay the full $350.00 filing fee before the Court will consider the m erits of m y com plaint. I m ust re que st an authorized official to com plete the attached Financial Certificate and I must attach a prin t-out reflecting all transactions in my inmate bank acc oun t for the full six (6) m onth period of tim e pre ced ing the filing of this com plaint. (a) If I have not been incarcerated at my current institution for six months, I must obtain an account statement from each facility at which I have been confined during the relevant six m onth period of time. Failure to subm it the req uired account sta tem ents m ay re sult in the denial of this in forma pauperis application. (b) Pursuant to the Prison Litigation Reform Act of 1995, 28 U.S.C. § 1915 (as amended), even if I am granted leave to proceed in form a pauperis, I must pay the entire $350.00 filing fee in full. I AM OBLIGATED TO PAY THE ENTIRE $350.00 FILING FEE REGARDLESS OF THE DIS PO SIT ION OF TH IS CAS E (including dismissal).

(c) If I am allowed to proceed in form a pauperis, I may still be required to submit an initial partial filing fee. 28 U .S.C . § 1915(b )(1). M y failure to s ubm it an initial partial filing fe e, if ass ess ed, m ay result in the dismissal of this case and the inability to proceed in form a pauperis in the future. (d) The officials at the institution at which I am presently confined or any institution to which I may be transferred are hereby authorized to mak e additional monthly payments from m y account until the balance of the $350.00 filing fee is paid. These additional monthly payments will be up to 20% of all the preceding m onth's deposits in m y account. Ins titution officials sha ll subm it these m onth ly paym ents directly to the Court whenever the funds in my account exceed $10.00. I recognize m y responsibility to alert officials at any institution to which I m ay be transferred in the future of my obligation to pay the full amount of the filing fee. I acknowledge that the Court m ay, from time to tim e, require me to provide additional financial records or acc oun t statem ents .

SIGNATURE OF PLAINTIFF

DATE

PRINTED NAME OF PLAINTIFF

INMATE NUM BER

** It is the inmate's responsibility to obtain the required print-out(s) from each institution at which he or she may have been confined during the preceding six months and provide them to the official completing this form . ************************************************* FINANCIAL CERTIFICATE (T o be com plete by Autho rized Penal O ffic ial) A P RIN TOUT OF A LL TR AN SACT IONS IN T HE INM AT E'S PRISON ACCOU NT FOR THE PRECEDING SIX (6) MONT HS MU ST BE ATTACHED.

1. 2. 3.

Current Account Balance: Average Monthly Balance for preceding 6 months: Average Monthly Deposits for preceding 6 months:

I hereby certify that, as of this date, the above information for the prison accou nt of the inm ate nam ed ab ove is correct.

SIG NAT UR E O F AU TH OR IZED OF FICIAL

DATE

PLEASE COMPLETE THIS FORM IN INK, IN A COLOR OTHER THAN BLACK. Revised 04/06

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Notice of Electronic Availability of Civil and Criminal Case File Information Effective Date: November 1st , 2004 Revised November 14th , 2006 The United States District Court for the Northern District of Florida accepts electronically filed pleadings and makes the content of these pleadings available on the court's Internet website via the Case Management/Electronic Case Files ("CM/ECF") system and/or PACER.1 Any subscriber to CM/ECF and/or PACER will be able to read, download, store, and print the full content of electronically filed documents. The clerk's office will not make electronically available documents that have been sealed or otherwise restricted by court order. You should not include sensitive information in any document filed with the court unless such inclusion is necessary and relevant to the case. You must remember that any personal information not otherwise protected will be made available over the Internet via CM/ECF and/or WebPACER. If sensitive information must be included, the following personal data identifiers must be partially redacted from the document, whether it is filed traditionally or electronically: Social Security numbers, financial account numbers, dates of birth, the names of minor children, and home addresses of parties. Disclosure of financial account and real property information in public electronic records, as is necessary to properly identify property in foreclosure and forfeiture proceedings, is an allowable exception. In compliance with the E-Government Act of 2002, a party wishing to file a document containing the personal data identifiers specified above may (a) file an unredacted document under seal, or (b) file a reference list under seal. The court may, however, still require the party to file a redacted copy for the public file. In addition, exercise caution when filing documents that contain the following: 1. Personal identifying number, such as driver's license number; 2. Medical records, treatment and diagnosis; 3. Employment history; 4. Individual financial information; and 5. Proprietary or trade secret information. Counsel are strongly urged to share this notice with all clients so that an informed decision about the inclusion of certain materials may be made. If a redacted document is filed, it is the sole responsibility of counsel and the parties to be sure that all pleadings comply with this notice requiring redaction of personal data identifiers. Likewise, counsel and the parties will be solely responsible for any unredacted documents filed. The Clerk's Office will not review documents for compliance with this notice, seal on its own motion documents containing personal identifiers, or redact documents, whether filed electronically or on paper.

Remote electronic access to pleadings filed in civil social security cases is limited to counsel of record and court staff. Non-parties have direct access to the pleadings on file at the Clerk's Office

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