ACKNOWLEDGMENT
I, the undersigned, acknowledge that I have read the foregoing and that the information
contained therein is true and correct to my own knowledge and belief.
Further, I state that I have not directly or indirectly paid or caused to be paid to any inmate,
agent of an inmate, or family member of any inmate a sum of money, favors or anything else for
assistance in the preparation of this document or any other document in connection with this action.
Further, I acknowledge that if any of the information included in this motion for leave to
proceed in forma pauperis is false or misleading, I understand that sanctions may be imposed against
me. Those sanctions may include, but are not limited to, the following:
(1)
dismissal of my case with prejudice;
(2)
imposition of monetary sanctions;
(3)
the Nevada Department of Prisons may bring disciplinary proceedings for a violation
of MJ-48 of the Code of Penal 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 Nevada, 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 or its representative.
Further, I acknowledge and consent that a portion of any recovery, as directed by the court,
shall be paid to the clerk for reimbursement of all fees and costs incurred by me as a result of being
granted leave to proceed in forma pauperis.
Dated this _____ day of ______________, 20___.
_______________________________
(Signature of Applicant)
I understand that a false statement or answer to any question in this declaration will subject
me to penalties of perjury. I DECLARE UNDER PENALTY OF PERJURY UNDER THE
LAWS OF THE UNITED STATES OF AMERICA THAT THE FOREGOING IS TRUE AND
CORRECT. See 28 U.S.C. § 1746 and 18 U.S.C. § 1621.
Signed at
(Location)
(Signature)
(Date)
(Inmate Prison Number)
IFP Motion
3
rev. eff. 7/21/2008 RJH