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Motion For Leave To Proceed In Forma Pauperis And Supporting Affidavit - Wyoming
| Motion For Leave To Proceed In Forma Pauperis And Supporting Affidavit Form. This is a Wyoming form and can be used in Prisoner District Court Federal . |
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Name Prisoner No. Address IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF WYOMING ____________________________________) ) ____________________________________) ) Plaintiff(s), ) ) vs. ) Case No. _______________ ____________________________________) ) ____________________________________) ) ____________________________________) ) Defendant(s). ) MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS AND SUPPORTING AFFIDAVIT (Pursuant to 28 U.S.C. 1915 and 28 U.S.C. 1746) I hereby apply for leave to: (Check one): _____ Commence this action for habeas corpus/civil rights relief _____ Pursue this action under 28 U.S.C. 2255 or Rule 35, F.R.Crim. P. Commence this appeal to the Tenth Circuit Court of Appeals without prepayment of fees or giving security therefor. Revised 4/97 1 of 11 <<<<<<<<<********>>>>>>>>>>>>> 2In support of my application, I state that the following facts are true: 1) I am the party initiating said action or appeal and I believe that I am entitled to relief. 2) The nature of this action or appeal is: ______________________________________________________ ______________________________________________________ ______________________________________________________ 3) I am unable to prepay the costs of this action or appeal or give security therefor because of my poverty. 4) I own the following assets: ______________________________________________________ ______________________________________________________ A) Do you own any cash or do you have money in a checking or savings account (include any funds in prison accounts, and any funds of deposit with a bank, savings & loan or certificates of deposit, outside the prison)? Yes _____ No _____ If the answer is "Yes", state the total value and location, including each account number, of the items owned (list the location of each account, type of account and amount or balance in the account): _________________________________________________ _________________________________________________Revised 4/97 2 of 11<<<<<<<<<********>>>>>>>>>>>>> 3 B) Do you own real estate, stocks, bonds, notes, automobiles or other valuable property? (exclude ordinary household furnishings and clothing) Yes _____ No _____ If the answer is "Yes", describe the property, its location, and state its approximate value: _________________________________________________ _________________________________________________ _________________________________________________ 5) Have you placed any property, assets or money in the name or custody of anyone else in the last two years? Yes _____ No _____ If the answer is "Yes", give the date, describe the property, assets or money, give the name of the person given custody of the item and the reason for the transfer. ______________________________________________________ ______________________________________________________ 6) Are you presently employed? Yes _____ No _____ A) If the answer is "Yes", state the amount of your salary or wages per month and give the name and address of your employer: _________________________________________________ _________________________________________________ Revised 4/97 3 of 11 <<<<<<<<<********>>>>>>>>>>>>> 4 B) If the answer is "No", state the date of last employment and the amount of the salary and wages per month which you received: __________________________________________________ __________________________________________________ 7) Have you received within the past twelve months any money from any of the following sources? A) Business, profession or form of self-employment? Yes _____ No _____ B) Rent payments, interest or dividends? Yes _____ No _____ C) Pensions, annuities or life insurance payments? Yes _____ No _____ D) Social security, Veterans Administration, disability pensions, workmens compensation or unemployment benefits? Yes _____ No _____ E) Gifts or inheritances? Yes _____ No _____ F) Any other sources? Yes _____ No _____Revised 4/97 4 of 11<<<<<<<<<********>>>>>>>>>>>>> 5 If the answer to any of the above is "Yes", describe each source of money and state the amount received from each during the past six months: ______________________________________________________ ______________________________________________________ ______________________________________________________ 8) List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support each month. ______________________________________________________ ______________________________________________________ 9) You may state briefly any additional financial or other information regarding your ability to pay the costs of this action: ______________________________________________________ ______________________________________________________ ______________________________________________________Revised 4/97 5 of 11<<<<<<<<<********>>>>>>>>>>>>> 6 ACKNOWLEDGMENT I, the undersigned, acknowledge that I have read the foregoing and that theinformation contained therein is true and correct to my knowledge and belief. Further, I acknowledge that if any of the information included in this motion forleave to proceed in forma pauperis is false or misleading, I understand that sanctionsmay be imposed against me. Those sanctions may include, but are not limited to, thefollowing: (1) dismissal of my case with prejudice; (2) imposition of monetary sanctions; (3) the Department of Corrections may bring disciplinary proceedings for a violation of the Code of Inmate Discipline, which can include all sanctions authorized under the Code including the loss of good time credits and punitive confinement; and (4) perjury charges. Further, I hereby authorize the United States District Court, District of Wyoming,or its representative, to investigate my financial status, and authorize any individual,corporation, or governmental entity to release any such information to the said Court orits representative. Further, I acknowledge that a portion of any recovery, as directed by the court,shall be paid to the clerk for reimbursement of all fees incurred by me as a result ofbeing granted leave to proceed in forma pauperis. Dated this ____ day of _________, ____. _____________________________ Signature of ApplicantRevised 4/97 6 of 11 <<<<<<<<<********>>>>>>>>>>>>> 7 I understand that a false statement or answer to any question in this affidavit willsubject me to penalties of perjury. I declare (or certify, verify or state) under penalty o
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