Free SF-1915.PDF - New Mexico

SF-1915 Leave to Proceed

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO

Plaintiff'(s)/Petitioner(s), v No. CIV

Defendant(s)/Respondent(s).

PRISONER'S MOTION AND AFFIDAVIT FOR LEAVE TO PROCEED PURSUANT TO 28 U.S.C. § 1915

I request leave to commence this civil action without prepayment of fees or security therefor pursuant to 28 U.S.C. § 1915. In support of my request, I declare that: (1) ( 2) I am unable to pay such fees or give security therefor. The nature of this action is:

(3) (4)

I am entitled to redress. I authorize the institution in which I am or have been incarcerated, to release any information concerning my inmate account(s) or other informationconcerning mv financial affairs. I further authorize the agency having custody of me to collect from my trust account and forward to the Clerk of this Court payments in accordance with 28 U.S.C. § 1915(b)(2).

SF-1915 Leave to Proceed

(5)

I acknowledge and consent that a portion of any recovery, as directed by the Court, shall be paid to the Clerk for reimbursement of all fees and costs incurred by me as a result of being granted leave to proceed in forma pauperis.

6)

My assets and their value are listed below: (Assets may include income from employment, rent payments, interest or dividends, pensions, annuities, life insurance payments, Social Security, Veteran's Administration benefits, disability pensions, Worker's Compensation, unemployment benefits, gifts or inheritances, cash, funds in bank accounts, funds in prison accounts, real estate, stocks, bonds, notes, automobiles or other valuable property (excluding ordinary household furnishings and clothing), or any other source of income.) You may attach an additional page, if necessary.

REQUIRED CERTIFICATION: you must attach to this motion and affidavit acertified
copy of your trust fund account statement (or institutional equivalent) for the six-month period immediately preceding the filing of this action. You must obtain the certifiedcopy of your trust fund account statement (or insututional equivalent) f'rom the appropriate official or each penal instritution at which you are or were confined during the- six-month period. " I declare under penalty of perjury that the foregoing is true and correct. Executed at ( location ) on (date)

Prisoner's Original Signature 2

SF-1915 Leave to Proceed

Additional Page for Item 6