Fill and Sign the Georgia Request to Proceed in Forma Pauperis Habeas Corpus

Revised�9�10 �14 � � R EQUEST F ORM TO P ROCEED I N FORMA PAUPERIS H ABEAS CORPUS I NSTRUCTIONS – R EAD CAREFULLY (NOTE: O.C.G.A. §9- 10-14(a) requires the proper use of this form, and failure to use this form as required will result in the clerk of any court refusing to accept the action for filing.) 1. Any action filed by an inmate of a state or local penal or correctional institution against the state or a local government or against any age ncy or officer of a state or local government must be filed on the appropriate form or forms promulgated by the Administrative Office of the Courts of Georgia. 2. This application must be legibly handwritten or typewrit ten, and signed by the petitioner. Any false statement of a material fact may se rve as the basis for prosecution for perjury. All questions must be answered concisely in the proper space on the form. 3. O.C.G.A. § 42-12 -1 et seq. provides that an inmate’s institutional account shall be frozen, and funds seized for court costs and fees. Add itionally, the filing of frivolous litigation shall result in a deduction from the account. 4. This affidavit of indigency must be accompanied by a certification from the institution wherein the inmate is incarcerated that the f inancial statement correctly states the amount of funds in any and all custodi al accounts held with the institution. 5. Any Request Form to Proceed In Forma Pauperis which does not conform to these instructions will be returned with a notation as to t he deficiency. 6. In no event shall a prisoner file any action in forma pa uperis in any court of this state if the prisoner has, on three or more prior occasions while he or she was incarcerated or detained in any facility, filed any action in any court of this state that was subsequently dismissed on the grounds that such actio n was frivolous or malicious, unless the prisoner is under imminent danger of serious physical injury. O.C.G.A. § 42-12 -7.2. 7. These forms may be obtained at the Administrative Of fice of the Courts’ website ( http://www. georgiacourts .gov/index.php/court-forms/101) or from the Administrative Office of the Courts through the head of th e institution in which the inmate is incarcerated. Administrative�Office�of�the�Courts�(Revised�9�10 �14 )�� [1]� HC�2� � � IN THE SUPERIOR COURT OF ___________________________ STATE OF GEORGIA ____________________________________ , Petitioner ____________________________________ , Civil Action No. _____________ ____________ Inmate Number vs. ____________________________________ , Habeas Corpus Warden ____________________________________ , Respondent (Name of Institution where you are now located) I, ____________________________________, depose and say that I am the plaintiff in the above entitled case; that in support of my request to proceed without being required to prepay fees, costs, or give security therefor, I state that because of my poverty I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am entitled to redress. I further swear that the responses which I have made to q uestions and instructions below are true. 1. List any and all aliases by which you are know n: ______________________________________ ______________________________________________________________________________ 2. Are you presently employed? Yes No If the answer is “Yes,” state the amount of your salary or wages per month, and give the nam e and address of your employer: ___ _______________________________________ ______ __________________________________________________________________ If the answer is “No,” state the date of last employm ent and the amount of the salary and wages per month which you received: _________________ ________________________ _ _______________________________________________________________________ 2. Have you received within the past twelve months any mo ney from any of the following sources? Business, profession, or form of self -employment? Yes No Pensions, annuities, o r life insurance payments? Yes No Rent payments, interest or dividends? Yes No REQUEST TO PROCEED IN FORMA PAUPERIS Administrative�Office�of�the�Courts�(Revised�9�10 �14 )�� [2]� HC�2� � � Gifts or inheritances? Yes No Any other sources? Yes No If the answer to a ny of the above is “Yes,” describe each source of money and state the amount received from each source during the past twelve months: ___________ _______ ________________________________________________________________________ ________________________________________________________________________ 3. Do you own any cash, or do y ou have money in a checking or savings account? (Include any funds in prison accounts): Yes No If the answer is “Yes,” state the total value of the items owned: _____________________ 4. Do you own any real estate, stocks, bonds, notes, aut omobiles, or other valuable property (excluding ordinary household furnishings and clothing)? Yes No If the answer is “Yes,” describe the property and state its approximate value: __________ ________________________________________________________________________ ________________________________________________________________________ 5. List the persons who are dependant upon you for fina ncial support, state your relationship to those persons, and indicate how you contribute toward their support: _____ __________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I u nderstand that a false statement or answer to any question in this a ffidavit will subject me to penalties for perjury and that state law provides as follows: a. A person to whom a lawful oath or affirmation has been administered commits the offense of p erjury when, in a judicial proceeding, he knowingly and willf ully makes a false statement material to the issue on point in question b. A person convicted of the offense of perjury shall b e punished by a fine of not more than $1,000 or by imprisonment fo r not less than one nor more than ten years, or both. O.G.C.A. § 16 -10 -70. _________________________________ _____________ Signature of Petitioner Date Administrative�Office�of�the�Courts�(Revised�9�10 �14 )�� [3]� HC�2� � � VERIFICATION I, ____ ________________________________ _ , do swear and affirm under pen alty of law that the statements contained in this affidavit are true. I fur ther attest that this application for in forma pauperis status is not presented to harass or to cause unnecessary de lay or needless increase in the costs of litigation . I am the pl aintiff in this action and know the content of the above Reques t to Proceed in Forma Pauperis. I verify that the answers I have given are true of my own knowledge, except as to those matters that are stated in it on my information and belief, and as to th ose matters I believe them to be true. I have read the perjury statute set out above and am aware of the penalties for giving any false information on this form. _________________________________ _____________ Signature of Affiant Petitioner Date Sworn to and subscribed before me this _______ day of ______________, 20____. ___________________________________________________ Notary Public or Other Person Authorized to Administer Oa ths Please note that under O.G.C.A. § 42 -12 -5 service of an affidavit in forma pauperis, inc luding all attachments, shall be made upon the court and all named defendants. Failure by the prisoner to comply with this code section shall result in dismissal without prejudice of the prisoner’s action. Administrative�Office�of�the�Courts�(Revised�9�10 �14 )�� [4]� HC�2� � � CERTIFICATION I hereby certify that the Plaintif f herein, __________________________________________ __, has an average monthly balance for the last twelve (12) months of $ ___________________ on a ccount at the _________________________________________________ _________________________________ ______________________________________ institution where confined. (If not confined for a full twelve (12) months, specify the number of months confined. Then compute the average monthly balance on that number of months.) I further certify that Plaintiff likewise has the following securities according to the records of said institution: ______________________________________________ _____________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ___________________________________ _________________ Authorized Officer of Institution Date THIS FORM IS TO BE COMPLETE D ONLY BY AN AUTHORIZ ED INDIVIDUAL AT THE INSTITUTION WHERE THE INMATE PLAINTIFF IS PRESENTLY INCARCE RATED, OR HIS/HER DESIGNEE. NOTE: Please attach a copy of the prisoner’s inmate account of the last 12 months, or the period of incarceration (whichever is less).