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UNITED STATES DISTRICT COURT D ISTRICT OF WYOMING , Plaintiff(s), vs. , Defendant(s). ) )))))))) Case No. MOTION TO PROCEED IN FORMA PAUPERIS AND SUPPORTING AFFIDAVIT I, declare that I am the (check appropriate box) G petitioner/plaintiff/movant G other in the above-entitled proceeding; that in support of my re quest to proceed without prepayment of fees or costs under 28 U.S.C. § 1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in the complaint/petition/motion. In support of this application, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? G Yes G No (If “No,” complete questions 2-6 ONLY. If “Yes,” complete all questions and pages 3 and 4.) If “Yes,” state the place of your incarceration. Are you employed at the institution? Do you receive any payment from the institution? Attach a statement from the institution(s) of your incarceration showing at least the past six months of your trust account. 2. Are you currently employed? G Yes G No a. If the answer is “Yes,” state the amount of your take-home salary or wages and pay period and give the name and address of your employer. -2- b. If the answer is “No,” state the date of your last employment, the amount of your take-home salary or wages and pay period and the name and address of your last employer. 3. In the past 12 months have you received any money from any of the following sources? a. Business, profession or other self-employment G Yes G No b. Rent payments, interest or dividends G Yes G No c. Pensions, annuities or life insurance payments G Yes G No d. Disability or workers’ compensation payments G Yes G No e. Gifts or inheritances G Yes G No f. Any other sources G Yes G No If the answer to any of the above is “Yes,” d escribe each source of money and state the amount received and what you expect you will continue to receive. If necessary, you may add a separate sheet of paper. 4. Do you have any cash or checking or savings accounts? G Yes G No If “Yes,” state the total amount. 5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other thing of value? G Yes G No If “Yes,” describe the property and state its value. 6. List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support. I hereby authorize the United States District Court, District of Wyoming, or its representative, to investigate my financial status, and authorize any individual, corporation, or governmental entity to release any such information to the Court or its representative. I declare under penalty of perjury that the above information is true and correct. Date Signature of Applicant -3- PRISONER FILING FEE INFORMATION (1) The filing fees are: Motion to Vacate Sentence (28 U.S.C. § 2255) $0.00 Petition for Writ of Habeas Corpus (28 U.S.C. § 2254) $5.00 Civil Rights Complaint $350.00All Appeals to Tenth Circuit $455.00 (2) If you are filing a petition for writ of habeas corpus, or are appealing a denial of a petition for writ of habeas corpus or a § 2255 motion, you must pay the entire filing fee unless you are granted leave to proceed without prepayment of fees or security under 28 U.S.C. § 1915(a)(1). (3) If you are filing a civil rights complaint or appeal, you are required to pay the entire filing fee, even if you are granted leave to proceed in forma pauperis. If you do not have sufficient funds in your trust account to pay the entire fee at this time, you will be required to make an initial partial payment of the filing fee and subsequent monthly payments until you have paid the entire filing fee. (A) Your initial partial payment will be 20% of your average monthly balance or the average monthly deposits to your account, whichever is greater. Thereafter, you must pay installments of 20% of the preceding m onth's income, including all deposits to your account; (B) You must continue to make installment payments until the filing fee is fully paid, without regard to whether your action is closed or you are released from confinement. PRISONER FILING FEE AUTHORIZATION I request and authorize my custodian to send to the Cl erk of the United States District Court for the District of Wyoming a certified copy of the statement for the past six months of my trust fund account (orinstitutional equivalent). I further request and author ize my custodian to remit the entire filing fee to the Clerk if I have sufficient funds in my trust account to pay the full fee. If I do not have sufficient funds to pay the full filing fee, I request and authorize the custodian to calculate and disburse funds from my trust account (or institutional equivalent) in the amounts specified by 28 U.S.C. § 1915(b). This authorization is furnished in connection with a civil action or appeal, and I understand that the total amount of the filing fee is $350.00 for a civil rights complaint and $455.00 for an appeal to the Tenth Circuit Court of Appeals. I also understand that these fees will be withdrawn from my account regardless of the outcome of my action or appeal . This authorization shall apply to any other institution to which I may be transferred. Dated: , 20___. Signature of Prisoner -4- CERTIFICATE OF PENAL INSTITUTION I hereby certify that on _______________, 20___, the prisoner herein had the following amount in his/her prisoner's trust fund account: ____________________ __________________ _______________________________________Date Signature of authorized trust fund officer _______________________________________ Printed or typed name of authorized officer _______________________________________ Title of authorized officer _______________________________________ Name of institution