Jailhouse Lawyer's Handbook - Sentencing and Justice Reform ...

: Civil Action No.
:
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I, ________________, am the petitioner / plaintiff in the
above entitled case. In support of my motion to proceed
without being required to prepay fees or costs or give
security therefore, I state that because of my poverty I am
unable to pay the costs of said proceeding or to give security
therefore, and that I believe I am entitled to redress.
I declare that the responses which I have made below are
true.
1. If you are presently employed, state the amount of your
salary wage per month, and give the name and address of
your employer ____________________________. (B)
2. If you are not presently employed state the date of last
employment and amount of salary per month that you
received and how long the employment lasted.
3. 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. Gifts or inheritances?
YES___ NO ___
e. Any form of public assistance?
YES___ NO ___
f. Any other sources?
YES___ NO ___
If the answer to any of questions (a) through (f) is yes,
describe each source of money and state the amount received
from each during the past months ________________.
4. Do you have any cash or money in a checking or savings
account? _______. If the answer is yes, state the total value
owned. (C)
5. Do you own any real estate, stock, bonds, notes,
automobiles, or other valuable property (including ordinary
household furnishings and clothing)? ____. If the answer is
yes, state the total value owned. ___________.
6. List the person(s) who are dependent on you for support,
state your relationship to those person(s), and indicate how
much you contribute toward their support at the present time.
_______________________.
7. If you live in a rented apartment or other rented building,
state how much you pay each month for rent. Do not include
rent contributed by other people. _______________. (D)
8. State any special financial circumstances which the court
should consider in this application.
_________________________________________________
____________________________________________.
I understand that a false statement or answer to any questions
in this declaration will subject me to the penalties of perjury.
I declare under penalty of perjury that the foregoing is true
and correct.
Signed this _______ day of ________, 20 ___.
_______________________
(your signature)
_______________________
Date of Birth
_______________________
Social Security Number
Explanation of Form:
In section (A), you can use a slightly shortened version
of the caption you used for your complaint. You only
need to list the first plaintiff and defendant by name.
The rest are included by the phrase “et al.” which
means “and others.” However, be aware that if there is
more than one plaintiff in your lawsuit, each plaintiff
needs to file his or her own declaration and application.
In section (B), if you have never been employed, just
say that. If you have a job in prison, state that.
In section (C), you should include any money you have
in a prison account.
Some of these questions may sound weird, or not apply
to you -- section (D) for example. However, answer
them anyway. Like for question 7, just state that you
do not live in an apartment.
Although the judge does not have to let you sue in
forma pauperis, he or she almost always will if you
show you are poor and your suit has some real legal
basis. You do not need to be absolutely broke. Section
1915(b)(1) of Title 28 directs the judge to compare the
monthly deposits and the average balance for your
prison account. He or she will figure that you can
initially pay twenty percent of the larger of these
numbers. If this is less than $150, then Section
1915(b)(2) states that you must pay twenty percent of
the monthly deposits to your account until the $150 is
paid. If the court decides you are not poor or your suit
is entirely “frivolous,” it will return your legal papers
and you will have to find a way to pay the full amount.
JAILHOUSE LAWYERS HANDBOOK – CHAPTER THREE
44