Free Request - District Court of Arizona - Arizona

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Name and Prisoner/Booking Number 1. 2
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PIM ¤f€<>¤t¥¤¤¤m¤¤¤ DISTRICT OF ARIZONA
P I OSEC; E athlon BY _ E DEPUTYJ
Mailing Address
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City, State, Zip Code

l IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
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vs. ) APPLICATION TO PROCEED
) HV FO}?/M4 PA UPEI?/S
VQLHEQEI IQb\§, I QQ, EI AL, , ) BYA PRISONER
Defendant(s). ) CIVIL (NON-HABEAS)
I, 5 bg D mm m ig Lqgl Q QQ; $5 , 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.
ln support of this application, 1 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? -S/es 1:lNo If "Yes," how many have you filed? ,5 .
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? [Wes .No If "Yes," how ma"ny”oTth`ein?Tw“wA I `IV`' In IWW
2. Are you currently employed at the institution where you are confined? [Wes .No
If "Yes," state the amount of your pay and where you work.
3. Do you receive any other payments from the institution where you are confined? [Wes .No
If "Yes," state the source and amount of the payments. .
4. Do you have any other sources of income, savings, or assets either inside or outside of the institution where
Revised 2/7/05 3.
Case 2:03—cv—01344-EHC-HCE Document 276 Filed 10/12/2006 Page1 of2

you are confined? IIIYBS IND
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.
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lol Or me .,,
DATE SIGNATURE OF APPLICANT

CONSENT TO COLLECTION OF FEES FROM TRUST ACCOUNT
I, Slnqnuqn Wighggl gjgglg , hereby consent to having the designated correctional official at t s
" .' - ` c o · .. · I -. can J W ; i T er consen o aving 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 filing fees in accordance with 28 U.S.C. § i9l 5(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 filing 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 Bling fee is paid in full. I understand that
I am liable for paying the entire fee, even if my case is dismissed by the Court before the fee is fully pai .
to I ji log, M
DATE i SIGNATURE OF APPLICANT `
. - CERTIFICATE OF CORRECTIONAL OFFICIAL
AS TO STATUS OF APPLICANT’S TRUST ACCOUNT
I, , certify that as of the date applicant signed this application:
(Printed name of official)
The appIicant’s trust account balance at this institution is: $
The appIicant’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
Revised 2/vos 2 .
Case 2:03—cv—01344-EHC-HCE Document 276 Filed 10/12/2006 Page 2 of 2

Case 2:03-cv-01344-EHC-HCE

Document 276

Filed 10/12/2006

Page 1 of 2

Case 2:03-cv-01344-EHC-HCE

Document 276

Filed 10/12/2006

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