Application To Proceed In Forma Pauperis - District Of Nevada (Page 4 of 4) in pdf

FINANCIAL CERTIFICATE

I request that an authorized officer of the institution in which I am confined, or other

designated entity, such as Inmate Services for the Nevada Department of Prisons (NDOC), complete

the below Financial Certificate.

I understand that:

(1) if I commence a petition for writ of habeas corpus in federal court pursuant to 28 U.S.C.

§ 2254, the filing fee is $5.00, and that such fee will have to be paid by me if the current account

balance (line #1 below), or the average account balance (line #2 below), or the average deposits to

my account (line #3), whichever is greater, is $20.00 or more;

(2) if I commence a civil rights action in federal court pursuant to 42 U.S.C. § 1983, the

filing fee is $350.00, which I must pay in full; and

(a) if my current account balance (line #1 below) is $350.00 or more, I will not

qualify for in forma pauperis status and I must pay the full filing fee of $350.00 before I will be

allowed to proceed with the action;

(b) if I do NOT have $350.00 in my account as reflected on line #1 below, before

I will be allowed to proceed with an action I will be required to pay 20% of my average monthly

balance (line #2 below), or the average monthly deposits to my account (line #3 below), whichever

is greater, and thereafter I must pay installments of 20% of the preceding month’s deposits to my

account in months that my account balance exceeds $10.00 (if I am in the custody of the NDOC, I

hereby authorize the NDOC to make such deductions from deposits to my account, and I further

understand that if I have a prison job, then the 20% of my paycheck that is guaranteed to me as

spendable money will be sent to the court for payment of the filing fee); and

paid, without regard to whether my action is closed or my release from confinement.

Type of action (check one): ____ civil rights

____ habeas corpus

INMATE NAME (printed)

SIGNATURE & PRISON NUMBER

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1. CURRENT ACCOUNT BALANCE

2. AVERAGE MONTHLY BALANCE*

3. AVERAGE MONTHLY DEPOSITS*

4. FILING FEE (based on #1, #2 or #3, whichever is greater)

* for the past six (6) months, from all sources, including amount in any savings

account that is in excess of minimum amount that must be maintained

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I hereby certify that as of this date, the above financial information is accurate for the above

named inmate.

(Please sign in ink in a)

(color other than black.)

AUTHORIZED OFFICER

DATE

TITLE

IFP Motion

rev. eff. 7/21/2008 RJH

Application To Proceed In Forma Pauperis - District Of Nevada Page 4