Free District of Montana Forma Pauperis Application - Montana


File Size: 73.8 kB
Pages: 6
Date: June 24, 2009
File Format: PDF
State: Montana
Category: Court Forms - Federal
Word Count: 1,389 Words, 9,007 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.mtd.uscourts.gov/pdf/Form%20IFP%20Mtn%2006232009.pdf

Download District of Montana Forma Pauperis Application ( 73.8 kB)


Preview District of Montana Forma Pauperis Application
IN THE UNITED STATES DISTRICT COURT DISTRICT OF MONTANA
_________________________________________ _________________________________________, (Full name of Plaintiff/Petitioner and prisoner number, if any)

Cause No._______________________
(to be filled in by Clerk of Court)

Plaintiff/Petitioner, vs.
_________________________________________ _________________________________________ _________________________________________, (Full name of each Defendant/Respondent. Do not use et. al.)

MOTION TO PROCEED IN FORMA PAUPERIS

Defendants. 1. My name is _________________________________________. In this action, I am (check one): a petitioner / plaintiff 9 a defendant 9 other (explain) 9_________________________________ In support of my request to proceed without prepayment of fees or costs under 28 U.S.C. § 1915, I declare I am unable to pay the costs of these proceedings and am entitled to relief in the action to which I am or will be a party. In support of this application, I answer the following questions under penalty of perjury.
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2.

Last Name of Plaintiff/Petitioner______________________________________ Motion to Proceed In Forma Pauperis (Revised 6/09)

3.

Are you currently employed? A.

Yes 9

No 9

If Yes, state the amount of your take-home salary or wages, your pay period, and the name and address of your employer:

B.

If No, state the date of your last employment, the amount of your take-home salary or wages, your pay period, and the name and address of your last employer:

4.

In the past twelve months, have you received any money from any of the following sources? A. Business, profession, or other self-employment Yes 9 No B. Rent payments, interest, or dividends Yes 9 No C. Pensions, annuities, or life insurance payments Yes 9 No D. Disability or workers compensation payments Yes 9 No E. Social Security or retirement benefits Yes 9 No F. Family or friends Yes 9 No G. Gifts or inheritances Yes 9 No H. Any other sources (specify) ________________ Yes 9 No If the answer to any of the above is Yes, describe each source of money, state the amount received, the frequency with which you receive it, and what you expect you will continue to receive:

9 9 9 9 9 9 9 9

5.

Do you have any cash or checking or savings accounts? Yes 9 If Yes, state the total value of all three:

No 9

6.

Do you own any automobiles, real estate, stocks, bonds, securities, trust, jewelry, art work, other financial instruments, or things of value, including any item of value held in someone else's name? Yes 9 No 9 If Yes, describe the property and state its approximate value:
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Last Name of Plaintiff/Petitioner______________________________________ Motion to Proceed In Forma Pauperis (Revised 6/09)

7.

Describe and provide the amount of any housing, transportation, utilities, loan payments, or other regular monthly expenses you may have.

8.

Name all persons dependent on you for support. State your relationship to each person and indicate how much you contribute to their support. If any of these individuals are under the age of 18, identify them by using their first and last initials only.

9.

Describe any debts or financial obligations you have, providing the amounts owed and to whom they are payable.

10.

TO BE COMPLETED BY PRISONERS ONLY NOTE: Prisoners are required to submit an official copy of their inmate trust account statement for the previous six months in support of this Application. You may include your account statement with this Application. A. State the place of your incarceration:

B.

If you have not been incarcerated at your current institution for the past six months, list all institutions in which you have been incarcerated in the past six months. State when you entered and when you left each institution.

C.

If you have not been incarcerated for the past six months, state the last date on which you were not incarcerated, and list any institutions at which you were incarcerated before your current one:

D.

Have you begun any other lawsuit while incarcerated or detained in any facility? Yes 9 No 9 (If No, go to Question 12)

Last Name of Plaintiff/Petitioner______________________________________ Motion to Proceed In Forma Pauperis (Revised 6/09)

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E.

For each prior lawsuit you have filed, provide the following information. Attach additional sheets as necessary. i. The court(s) where each lawsuit was filed. (For federal courts, identify the District; for state courts, identify the county. Do not include lawsuits filed in the U.S. District Court for the District of Montana);

ii.

The parties to the previous lawsuit(s);

iii.

The docket number(s) for each prior lawsuit;

iv.

The date(s) on which each lawsuit was filed;

v.

How and when each lawsuit was resolved (For example, was the case dismissed? Was it settled? Was it appealed? By whom, plaintiff or defendant? Is the case still pending?);

vi.

Whether the prior lawsuit was based upon the same or similar facts asserted in this lawsuit; and

vii.

Whether any prior lawsuits were dismissed as frivolous, malicious, or for failure to state a claim, and if so which ones.

F.

If you filed any appeal in any federal court of appeals, name the court(s) and give the case number(s) and the disposition.

Last Name of Plaintiff/Petitioner______________________________________ Motion to Proceed In Forma Pauperis (Revised 6/09)

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11.

Applicant's Declaration A. I understand I must keep the Court informed of my current mailing address and my failure to do so may result in denial of this Application without actual notice to me. I understand the Federal Rules of Civil Procedure prohibit litigants in non-habeas proceedings from using certain information in documents submitted to the Court. In order to comply with these rules, I understand that: · social security numbers, taxpayer identification numbers, and financial account numbers must include only the last four digits (e.g. xxx-xx-5271, xx-xxx5271, xxxxxxxx3567); · birth dates must include the year of birth only (e.g. xx/xx/2001); and · names of persons under the age of 18 must include initials only (e.g. L.K.).

B.

If my documents (including exhibits) contain any of the above listed information, I understand it is my responsibility to black that information out before sending those documents to the Court. I understand that if I am a habeas litigant I may, but am not required to, follow these rules. I understand I am responsible for protecting the privacy of this information in a non-habeas case.

C.

(Prisoners Only): I understand I may not proceed in forma pauperis if I have filed three lawsuits and/or appeals that were dismissed on grounds the action and/or appeal was frivolous or malicious, or failed to state a claim upon which relief may be granted, unless I am in imminent danger of serious physical injury. 28 U.S.C. § 1915(g).
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Last Name of Plaintiff/Petitioner______________________________________ Motion to Proceed In Forma Pauperis (Revised 6/09)

D.

I understand the submission of a false statement or answer to any question in this Application may subject me to penalties for perjury. I, the Applicant, declare under penalty of perjury that I have read the above Application and the information I have set forth within it is true and correct. 28 U.S.C. § 1746; 18 U.S.C. § 1621. ________________________________________
Signature of Applicant (sign in presence of Notary Public)

To be completed by Notary Public: I hereby certify that on this day the Applicant, ____________________________, personally appeared before me, a Notary Public for the State of Montana. The Applicant swears or affirms that s/he is the person named in the foregoing Application, that s/he has read and truthfully completed the contents thereof, and that s/he has executed the Application by his/her own hand. The Application was SUBSCRIBED AND SWORN before me this ___ day of ___________________, 20____.

(seal)

______________________________________ Printed Name ____________________________________________ Notary Public, State of Montana, County of __________ My Commission Expires _________________________

Special Note: Pro Se litigants proceeding in forma pauperis are not exempt from other fees and costs associated with prosecuting their actions, including but not limited to copying and witness fees. It is important to realize that even if you are proceeding with an action in forma pauperis, neither the Court nor the Clerk's office can make copies for you free of charge. Copies of documents in your file cannot be provided to you by the Clerk's Office without a charge of $0.50 per page which must be pre-paid at the time you make your request. Therefore, you should always keep a copy, for your own records, of all documents you send to the Court or to the Clerk's Office.

Last Name of Plaintiff/Petitioner______________________________________ Motion to Proceed In Forma Pauperis (Revised 6/09)

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