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Page 1 Case 3:08-cv-01484-WHA Document6 Filed 05/07/2008 Page 1 of 7
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PRIS. APP. TO PR
_ UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF CALIFORNIA
Piaintift, 9 cAsENO.OZLYSY
vs. | } PRISONER’S
APPLICATION TO PROCEED
IN FORMA PAUPERIS
Defendant. }
___) -
1, Clrarles Joh N56N _, declare, under penalty of perjury that I am the
plaintiff in the above entitled case and that the information | offer throughout this application
is true and correct. | offer this application in support of my request to proceed without being
required to prepay the full amount of fees, costs or give security. I state that because of my
poverty I am unable to pay the costs of this action or give security, and that I believe that I am
entitled to relief.
In support of this application, I provide the following information:
1, Are you presently employed? Yes____ ~No vv
If your answer is "yes," state both your gross and net salary or wages per month, and give the
name and address of your employer:
Gross: Net:
Employer:
IC. IN FORMA PAUPERIS -l-Page 2 Case 3:08-cv-01484-WHA Document6 ~~ Filed 05/07/2008 Page 2 of 7
1 || If the answer is "no," state the date of last employment and the amount of the gross and net
2 || salary and wages per month which you received. (If you are imprisoned, specify the last
3 || place of employment prior to imprisonment.)
4|_Z have never been Eurg loved
; :
6
7 | 2. Have you received, within the past twelve (12) months, any money from any of the
8 || following sources: ‘ | |
94. a., Business, Profession or ‘ Yes____—No x
self employment
1] b. Income from stocks, bonds, Yes___ No om
or royalties? | - :
c Rent payments? Yes___—s—~-No aa
d Pensions, annuities, or Yes___s No ae
life insurance payments? .
e Federal or State welfare payments, Yes____ No mm
17 Social Security or other govern-
ment source?
19 || If the answer is "yes" to any of the above, describe each source of money and state the amount
received from each. |
21
22
23 3. Are you married? Yes____—~‘No Vo
24 Spouse's Full Name:
25 || Spouse's Place of Employment:
26 || Spouse's Monthly Salary, Wages or Income:
27 || Gross $ _ Net $
28 | 4. a. __ List amount you contribute to your spouse's support:$
-2-
PRIS. APP. TO PRGIC. IN FORMA PAUPERISPage 3 Sy
Case 3:08-cv-01484-WHA Document6 Filed 05/07/2008 Page 3 of 7
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b. List the persons other than your spouse who are dependent upon you for
support and indicate how much you contribute toward their support. (NOTE:
For minor children, list only their initials and ages. DO NOT INCLUDE
THEIR NAMES.).
5. Do you own or are you buying a home? Yes No_W
Estimated Market Value: $ __ Amount of Mortgage: $ |
6. Do you own an automobile? ‘Yes No Va
Make Year Model
Is it financed? Yes No If so, Total due: $
Monthly Payment: $
7. Do you have abank account? Yes No “Do not include account numbers.)
Name(s) and address(es) of bank:
Present balance(s): $
Do you own anycash? Yes___. No Amount: $
Do you have any other assets? (If "yes,’ provide a description of each asset and its estimated
market value.) Yes_ = No_*.
8. What are your monthly expenses?
Rent: $ Utilities:
Food: $ Clothing:
Charge Accounts:
Name of Account Monthly Payment Total Owed on This Acct.
$ $
$ $
$ $
PRIS. APP. TO ree IN FORMA PAUPERIS -3-Page 4 Case
CoD I DN PF WwW PB
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eo YA unE OHH SSERDVTADE DES
3:08-cv-01484-WHA Document6 Filed 05/07/2008 Page 4of7
9. Do you have any other debts? (List current obligations, indicating amounts and to
whom they are payable. Do not include account numbers.)
10. Does the complaiit which you are seeking to file raise claims that have been presented
in other lawsuits? Yes No
Please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in
which they were filed.
I consent to prison officials withdrawing from my trust account and paying to the court
the initial partial filing fee and all installment payments required by the court.
I declare under the penalty of perjury that the foregoing is true and correct and
understand that a false statement herein may result in the dismissal of my claims.
t/-24-2008 Chrales bearer
DATE SIGNATURE OF APPLICANT
PRIS. APP. TO PR
IC. IN FORMA PAUPERISPage 5 10
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Case 3:08-cv-01484-WHA Document6 Filed 05/07/2008 Page 5 of 7
Case Number: OG / AS i
CERTIFICATE OF FUNDS
IN
PRISONER'S ACCOUNT
TIGUS
I certify that attached hereto is a true and correct copy of the prisoner's trust account
statement showing transactions of CHMES Dolson for the last six months
at
[prisoner name]
_ Spa Queastip) where (s)he is confined.
[name of institution]
I further certify that the average.deposits each month to this prisoner's account for the
most recent 6-month period were $_2°7,6.2 and the average balance in the prisoner's
account each month for the most recent 6-month period was $27, 6.3. .
Dated: 5/5/O@
[Authorized officer of the institution]Page 6 REPORT ID:
7§ 2688 :08-25-01484-WHA
Document 6
Filed 05/07/2008 RagemripaATE: 05/05/70
PAGE NOG:
CALIFORNIA DEPARTMENT OF CORRECTIONS
INMATE
INMATE
BN; CHARLES
7 -NAME—
PRIVILEG 3E GROUP: U
D: NOV. OS, 2007 THRU MAY 05, 2008
S4N QUENTIN PRISON
TRUST ACCOUNTING SYSTEM
TRUST ACCOUNT STATEMENT
-BED/CELL NUMBER: “D a 00000000002L. _
ACCOUNT TYPE: TI
rhemecd
Ce Ps
TRUST ACCOUNT ACTIVITY
“SATE CEBE_BEBCRHIS SDN 7 oRREN TS CHECK DERDSETS EE THDRAGALS SEEMS
TRAN
st gt meet ete ane | Sah ome era ermey tht ttn in. ste a nt ator hi
11/05/2007 Q BEGINNING BA ANCE
se ae Hn me seem ctr ene nym tome ene’ car mes Set a Hy et aoe, ce atte rete ms a
-- 0.00
ACTIVITY FOR 2008
O4/P64DD36G CASH BEPOSIT 3764/ROR 165.462 165.62
04/08 FCOi DRAW-FAC 1 3935/M 1ST 70.00 75.62
| > RESTITUTION ACCOUNT ACTIVITY
SATE SENTENCED /aavos—— ease NUMBER: tases — 2 —
COUNTY COBE: ALA | | FINE AMOUNT. & 400, 60
DATE TRANS. DESCRIPTION TRANS. AMT, BALANCE
BEGINNING gs pe ENS ents oe 400. 00
“asaesog pRaO REST DEB_casH-bepagEt————— te og 9.
* THIS STATEMENT DOES NOT REFLECT THE ADMINISTRATIVE FEE CHARGE THAT #
# 18 EQUAL TO TEN PERCENT OF THE RESTITUTION AMOUNT COLLECTED.
as TRUST ACCOUNT SUMMARY
- BEGINNENO eye” eg Fa —— CURRENT ~~~ H@L-DS TRANS CEEONS-—
BALANCE DEPOSITS WITHDRAWALS BALANCE BALANCE TO BE POSTED
CURRENT
AVATAR LE
BALANCEPage 7 Case 3:08-cv-01484-WHA Document6 — Filed 05/07/2008 . Page 7 of 7
PDF Page 1
PlainSite Cover Page
PDF Page 2
Case 3:08-cv-01484-WHA Document6 Filed 05/07/2008 Page 1 of 7
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PRIS. APP. TO PR
_ UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF CALIFORNIA
Piaintift, 9 cAsENO.OZLYSY
vs. | } PRISONER’S
APPLICATION TO PROCEED
IN FORMA PAUPERIS
Defendant. }
___) -
1, Clrarles Joh N56N _, declare, under penalty of perjury that I am the
plaintiff in the above entitled case and that the information | offer throughout this application
is true and correct. | offer this application in support of my request to proceed without being
required to prepay the full amount of fees, costs or give security. I state that because of my
poverty I am unable to pay the costs of this action or give security, and that I believe that I am
entitled to relief.
In support of this application, I provide the following information:
1, Are you presently employed? Yes____ ~No vv
If your answer is "yes," state both your gross and net salary or wages per month, and give the
name and address of your employer:
Gross: Net:
Employer:
IC. IN FORMA PAUPERIS -l-
PDF Page 3
Case 3:08-cv-01484-WHA Document6 ~~ Filed 05/07/2008 Page 2 of 7
1 || If the answer is "no," state the date of last employment and the amount of the gross and net
2 || salary and wages per month which you received. (If you are imprisoned, specify the last
3 || place of employment prior to imprisonment.)
4|_Z have never been Eurg loved
; :
6
7 | 2. Have you received, within the past twelve (12) months, any money from any of the
8 || following sources: ‘ | |
94. a., Business, Profession or ‘ Yes____—No x
10 self employment
1] b. Income from stocks, bonds, Yes___ No om
12 or royalties? | - :
13 c Rent payments? Yes___—s—~-No aa
14 d Pensions, annuities, or Yes___s No ae
15 life insurance payments? .
16 e Federal or State welfare payments, Yes____ No mm
17 Social Security or other govern-
18 ment source?
19 || If the answer is "yes" to any of the above, describe each source of money and state the amount
20 received from each. |
21
22
23 3. Are you married? Yes____—~‘No Vo
24 Spouse's Full Name:
25 || Spouse's Place of Employment:
26 || Spouse's Monthly Salary, Wages or Income:
27 || Gross $ _ Net $
28 | 4. a. __ List amount you contribute to your spouse's support:$
-2-
PRIS. APP. TO PRGIC. IN FORMA PAUPERIS
PDF Page 4
Sy
Case 3:08-cv-01484-WHA Document6 Filed 05/07/2008 Page 3 of 7
oO SI DH A KR WwW PB &
7,
NNN BY YW HN PL we
IAW ER YU YH & SO KH KX ABR ORAS
N
oo
b. List the persons other than your spouse who are dependent upon you for
support and indicate how much you contribute toward their support. (NOTE:
For minor children, list only their initials and ages. DO NOT INCLUDE
THEIR NAMES.).
5. Do you own or are you buying a home? Yes No_W
Estimated Market Value: $ __ Amount of Mortgage: $ |
6. Do you own an automobile? ‘Yes No Va
Make Year Model
Is it financed? Yes No If so, Total due: $
Monthly Payment: $
7. Do you have abank account? Yes No “Do not include account numbers.)
Name(s) and address(es) of bank:
Present balance(s): $
Do you own anycash? Yes___. No Amount: $
Do you have any other assets? (If "yes,’ provide a description of each asset and its estimated
market value.) Yes_ = No_*.
8. What are your monthly expenses?
Rent: $ Utilities:
Food: $ Clothing:
Charge Accounts:
Name of Account Monthly Payment Total Owed on This Acct.
$ $
$ $
$ $
PRIS. APP. TO ree IN FORMA PAUPERIS -3-
PDF Page 5
Case
CoD I DN PF WwW PB
MN YN YW HN Ww
eo YA unE OHH SSERDVTADE DES
3:08-cv-01484-WHA Document6 Filed 05/07/2008 Page 4of7
9. Do you have any other debts? (List current obligations, indicating amounts and to
whom they are payable. Do not include account numbers.)
10. Does the complaiit which you are seeking to file raise claims that have been presented
in other lawsuits? Yes No
Please list the case name(s) and number(s) of the prior lawsuit(s), and the name of the court in
which they were filed.
I consent to prison officials withdrawing from my trust account and paying to the court
the initial partial filing fee and all installment payments required by the court.
I declare under the penalty of perjury that the foregoing is true and correct and
understand that a false statement herein may result in the dismissal of my claims.
t/-24-2008 Chrales bearer
DATE SIGNATURE OF APPLICANT
PRIS. APP. TO PR
IC. IN FORMA PAUPERIS
PDF Page 6
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Case 3:08-cv-01484-WHA Document6 Filed 05/07/2008 Page 5 of 7
Case Number: OG / AS i
CERTIFICATE OF FUNDS
IN
PRISONER'S ACCOUNT
TIGUS
I certify that attached hereto is a true and correct copy of the prisoner's trust account
statement showing transactions of CHMES Dolson for the last six months
at
[prisoner name]
_ Spa Queastip) where (s)he is confined.
[name of institution]
I further certify that the average.deposits each month to this prisoner's account for the
most recent 6-month period were $_2°7,6.2 and the average balance in the prisoner's
account each month for the most recent 6-month period was $27, 6.3. .
Dated: 5/5/O@
[Authorized officer of the institution]
PDF Page 7
REPORT ID:
7§ 2688 :08-25-01484-WHA
Document 6
Filed 05/07/2008 RagemripaATE: 05/05/70
PAGE NOG:
CALIFORNIA DEPARTMENT OF CORRECTIONS
INMATE
INMATE
BN; CHARLES
7 -NAME—
PRIVILEG 3E GROUP: U
D: NOV. OS, 2007 THRU MAY 05, 2008
S4N QUENTIN PRISON
TRUST ACCOUNTING SYSTEM
TRUST ACCOUNT STATEMENT
-BED/CELL NUMBER: “D a 00000000002L. _
ACCOUNT TYPE: TI
rhemecd
Ce Ps
TRUST ACCOUNT ACTIVITY
“SATE CEBE_BEBCRHIS SDN 7 oRREN TS CHECK DERDSETS EE THDRAGALS SEEMS
TRAN
st gt meet ete ane | Sah ome era ermey tht ttn in. ste a nt ator hi
11/05/2007 Q BEGINNING BA ANCE
se ae Hn me seem ctr ene nym tome ene’ car mes Set a Hy et aoe, ce atte rete ms a
-- 0.00
ACTIVITY FOR 2008
O4/P64DD36G CASH BEPOSIT 3764/ROR 165.462 165.62
04/08 FCOi DRAW-FAC 1 3935/M 1ST 70.00 75.62
| > RESTITUTION ACCOUNT ACTIVITY
SATE SENTENCED /aavos—— ease NUMBER: tases — 2 —
COUNTY COBE: ALA | | FINE AMOUNT. & 400, 60
DATE TRANS. DESCRIPTION TRANS. AMT, BALANCE
BEGINNING gs pe ENS ents oe 400. 00
“asaesog pRaO REST DEB_casH-bepagEt————— te og 9.
* THIS STATEMENT DOES NOT REFLECT THE ADMINISTRATIVE FEE CHARGE THAT #
# 18 EQUAL TO TEN PERCENT OF THE RESTITUTION AMOUNT COLLECTED.
as TRUST ACCOUNT SUMMARY
- BEGINNENO eye” eg Fa —— CURRENT ~~~ H@L-DS TRANS CEEONS-—
BALANCE DEPOSITS WITHDRAWALS BALANCE BALANCE TO BE POSTED
CURRENT
AVATAR LE
BALANCE
PDF Page 8
Case 3:08-cv-01484-WHA Document6 — Filed 05/07/2008 . Page 7 of 7
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