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Application For In Forma Pauperis Status (Prisoner) - Idaho
| Application For In Forma Pauperis Status (Prisoner) Form. This is a Idaho form and can be used in District Court Federal . |
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_______________________________________ (full name/prisoner number) _______________________________________ _______________________________________ _______________________________________ (complete mailing address) Plaintiff/Petitioner UNITED STATES DISTRICT COURT FOR THE DISTRICT OF IDAHO __________________________________, (full name) Plaintiff/Petitioner, v. ____________________________________ ____________________________________ ____________________________________ ____________________________________ Defendant/Respondent. (if you need additional space, use a blank page for a continuation page) Case No. (to be assigned by Court) PRISONER APPLICATION TO PROCEED IN FORMA PAUPERIS By completing this Application, I am requesting in forma pauperis status rather than paying the filing fee at the time of filing. I understand that, if my request is granted in a civil rights case, my fee will not be waived, but I will be responsible to pay the entire fee from my prison trust account in increments, when and as I am able to do so. If my request is granted in a habeas corpus case, the fee will be waived. 1. Are you employed? Yes ____ No. _____. If employed, please state your job title and the total amount of wages you make per month. _______________________________________ Job Title 2. $__________ per month Within the past six (6) months, have you received any money from any of the following sources? a. Business, or other form of self-employment? Yes___ No___ b. Rent payments, interest or dividends? Yes___ No___ APPLICATION TO PROCEED IN FORMA PAUPERIS - 1 (Rev. 10/24/2011) American LegalNet, Inc. www.FormsWorkFlow.com 1 PRISONER c. d. e f. g. Pensions, annuities, or life insurance payments? Welfare, social security, or disability benefits? Gifts or inheritances? Friends or family? Any other sources? ______________________ (identify source) Yes___ No___ Yes___ No ___ Yes___ No___ Yes___ No___ Yes___ No___ 3. 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 (six) months. ________________________________________________________________________ ________________________________________________________________________ Do you own or have any interest in any real estate, stocks, bonds, notes, automobiles or other valuable property? Yes____ No____. If the answer is "yes," describe the property and state its approximate value. ________________________________________________________________ ________________________________________________________________ 4. 5. List the persons who are dependent upon your support, state your relationship to those persons, and indicate how much you contribute or are obligated to contribute, toward their support. Person ___________________ ___________________ Relationship _________________ _________________ Due Each Month $___________ $___________ 6. I have attached a Prison Trust Account Statement to this Form. Yes____ No____. I declare under penalty of perjury that the foregoing is true and correct. Executed on this ____ day of ________________________, ________. ___________________________ Plaintiff/Petitioner Notes: You do not need to send a copy of this document to Defendant/Respondent. This Application must be accompanied by a Prison Trust Account Statement. This Application takes the place of an in forma pauperis motion and affidavit. Notarization is not necessary because the Application is signed under penalty of perjury. 2 PRISONER APPLICATION TO PROCEED IN FORMA PAUPERIS - 2 (Rev. 10/24/2011) American LegalNet, Inc. www.FormsWorkFlow.com
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