Free Motion for Leave to Appeal in forma pauperis - District Court of Arizona - Arizona

_;Q_ FILED LODGED
$:3;;;-: §_3,;\ §;` Shgf 5;; 'R 2; §S`) Q _____ RECEIVED ______ COPY
Name and Prisoner/Booking Number
Hamm $53 Egg am rra; 5,,,,, MAY 1 2 2005
Place of Confinement
_ CLERK U S DISTRICT cruznr
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Mailing Address BYHW-"“_·HHF_ {QH Di ·~!_|T·Y
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Citgn State, Zip Code
IIN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
)
wares egg.; It Saga sr. ,)CASE No. gy as - ga gu was- gu; gems
Plaintiff, )
)
vs. ) APPLICATION TO PROCEED
n ) IN F ORMA PA UPERIS
`bsiaa got-} Etggl Ei Q3. , ) BY A PRISONER
Defendant(s). ) CIVIL (NON-HABEAS)

I, fag; gse; jj gym-{ { ‘e.r. , 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. Have you ever before brought an action or appeal in a federal court while you were incarcerated or detained?
EYes i;iNo If "Yes," how many have you filed? 5 . E
Were any of the actions or appeals dismissed because they were frivolous, malicious, or failed to state a
claim upon which relief may be granted? I;iYes ENo If "Yes," how many of them? __.
2. Are you currently employed at the institution where you are confined? BYes i;iNo
If "Yes, " state the amount of your pay and where you work.
3,99;,; 3 3 kgs, Eg gjgigi
3. Do you receive any other payments from the institution where you are confined? |:iYes E?No
If "Yes," state the source and amount of the payments.
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4. Do you have any other sources of income, savings, or assets either inside or outside of the institution where
you are confined? I:lYes E?No
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 SIGNA RE OF APPL ANT

CONSENT T O COLLECTION OF FEES FROM TRUST ACCOUNT
I, V hggn §;,;§ Ti s§g iq hereby consent to having the designated correctional officials at this
institution release to the Court my trust account information. I iinrther consent to having the designated
correctional officials at this institution withdraw from my trust account the funds required to comply with the
order of this Court for the payment of tiling fees in accordance with 28 U.S.C. § 1915(b).
My consent includes withdrawal from my account by correctional officials of partial initial payments to this
Court equal to 20% of the greater of:
(A) the average monthly deposits to my account for the six—month period preceding my filing of this
action, or
(B) the average monthly balance in my account for the six-month period preceding my tiling of this
action.
My consent also includes monthly withdrawals from my account by correctional officials of an amount equal
to 20% of each month’s income. Whenever the amount in my account reaches $10, correctional officials will
withdraw that amount and forward it to the Court until the required filing fee is paid in full. I underst ·• that
I am liable for paying the entire fee, even if my case is ·. ismissed! •· ourt r e fe .
esa 2
DATE SIGNATURE F APPLICANT

CERTIFICATE OF CORRECTIONAL OFFICIAL
AS TO STATUS OF APPLICANTS TRUST ACCOUNT
I, , certify that as of the date applicant signed this application:
(Printed name of official)
The applicant’s trust account balance at this institution is: $
The applicant’s average monthly deposits during the prior six months is: $___
The applicant’s average monthly balance during the prior six months is: $______________________,
The attached certified account statement accurately reflects the status of the applicant’s account.
DATE AUTHORIZED SIGNATURE TITLE/ID NUMBER INSTITUTION
2
Case 2:04—cv—00434-EHC—ECV Document 69 Filed 05/12/2006 Page 2 of 3

J} , ,. -
1 VERIFICATION
2 STATE OF ARIZONA
ss.
3 County of Vtmth Verification of
4 g I, cfg; M E écg g kg Qt, , being iirst duly sworn upon oath, deposes and says as
5 follows:
6 l. I am the named PlaintiH` in the civil action known as Complaint for violation of
1
7 [idenfijjz either civil rights or coridifions ofconjinement] Q`, g`, \ 3 {E x js n .
S 2. I have read the foregoing pleading, and know the contents thereof.
9 3. The statements and matters alleged therein are tmc of my own personal knowledge,
10 except as to those matters stated upon information and belief and, as to such matters, I believe
11 them to be true.
!
12 DATEDthis 20% day of /l/lk` - , gotcé. .
13 { ‘
14
· (Plaintiff Signature)
15 `
Faq; §2;\“'\'i since St-,
16 (Typed/Printed Name)
17 §3xg`..ér`.QR’
(Pain)
18 .
19 State of Anzona
20 County of _? x ma
21 On this day of m Bd , 3 ga g, , before me personally appeared
22 Eg: an gk; I', $-3 EE 5, . (name of signer), whose identity was proved to me on the
basis of satisfactoxy evidence to be the person whose name is subscribed to this instrument, and
23 acknowledged he executed the same.
24 {-·-,_;··-····sz;arsaT""3
25 = low K. MEADE ;
! "'°""" !
28 i (My Commission Expi es)
- 3 -
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Case 2:04-cv-00434-EHC-ECV

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Case 2:04-cv-00434-EHC-ECV

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