Free Application to Proceed IFP by a Prisoner - Hawaii

IFP FORM Rev.0 1/08

UNITED STATES DISTRICT COURT
DISTRICT OF HAWAII

Plaintiff vs.

APPLICATION TO PROCEED IN FORMA PAUPERIS BY A PRISONER

Defendant

CASE NUMBER:

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 give security therefor and that I believe 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?: If "Yes" state the place of your incarceration. G Yes G No (If "No" Do not use this form)

2. Are you currently employed at the institution where you are confined? G Yes G No If the answer is "Yes" state the amount of your pay. _____________________________________________ 3. Do you have any other sources of income, savings, or assets? G Yes G No If "Yes," state the source and the amount of the payments. Attach an additional sheet if necessary. _________________________________________________________________________________________ 4. Do you own real estate, stocks, bonds, securities, other financial instruments, automobiles, or other property? G Yes If "Yes" describe the property and state its value.

G No

5. 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. __________________________________________________________________________________________ 6. Have you been granted in forma pauperis status while a prisoner, in three or more prior actions which have been dismissed because they were frivolous, malicious, or failed to state a claim upon which relief may be granted? G Yes* G No
*You may not proceed in forma pauperis if as a prisoner, you have had three or more actions dismissed as frivolous, malicious, or for failure to state a claim, unless you are under imminent danger of serious physical injury. 28 U.S.C. § 1915(g).

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

DATE

SIGNATURE and PRISON NUMBER OF APPLICANT

IFP FORM Rev.0 1/08

FINANCIAL CERTIFICATE AND CONSENT TO COLLECTION OF FEES I request an authorized officer of the institution in which I am confined, or other designated entity, complete the Certificate below. I 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 in accordance with 28 U.S.C. § 1915(b)(2). I understand that if I cause a civil action to be opened, the filing fee is $350.00, and: (1) if my current account balance is sufficient to qualify as a pauper, yet in excess of $360.00, I will be granted in forma pauperis status for service purposes but will be required to immediately pay the filing fee in full. if my current account balance is sufficient to qualify as a pauper, and the amount in my account is below $350.00, I will be required to pay 20% of my average monthly balance, or 20% of the average monthly deposits to my account, whichever is greater, and thereafter I must pay installments of 20% of the preceding month's deposits to my account in months that my account balance exceeds $10.00. I must continue to make installment payments until the $350.00 filing fee is fully paid without regard to whether my action is closed or my release from confinement.

(2)

(3)

An inmate granted in forma pauperis status in a habeas corpus action will not be required to make installment payments on the $5.00 filing fee. See Naddi v. Hill, 106 F.3d 275, 276 (9th Cir. 1997). I declare under penalty of perjury that the above information is true and correct.

DATE

SIGNATURE and PRISON NUMBER OF APPLICANT

CERTIFICATE (To be completed by the institution of incarceration) 1. 2. 3. 4. on account [spendable and I certify that the applicant named herein has the sum of $ restricted] 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 transactions for the past six months.

DATE

SIGNATURE OF AUTHORIZED OFFICER

* attach copy of prisoner's past six month's prison trust account balance statement *