Fill and Sign the Prisoner Forms and Instructionsnorthern District of Georgia

� Revised�9�10 �14 � � R EQUEST F ORM TO P ROCEED I N FORMA PAUPERIS C IVIL A CTION 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 ac tion 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. Additionally, 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 financial statement correctly states the amount of funds in any and all cu stodial accounts held with the institution. 5. Any Request Form to Proceed In Forma Pauperis which does n ot conform to these instructions will be returned with a notation as to the deficiency. 6. In no event shall a prisoner file any action in forma pau peris 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 the institution in which the inmate is incarcerated. � Administrative�Office�of�the�Courts�( Revised�9�10 �14 )� � [1]�� � � � � F orm�CA�2� IN THE SUPERIOR COURT OF ___________________________ STATE OF GEORGIA ____________________________________ , Plaintiff ____________________________________ , Civil Action No. _____________ ____________ Inmate Number vs. Nature of Action: ____________________________________ , _______________________________________ ____________________________________ , _______________________________________ ____________________________________, ______________________________________ _ Defendant(s) 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 e, I state that because of my poverty I am unable to pay the costs of said proce eding or to give security therefor e; 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 known: _____________________________ ________ ______________________________________________________________________________ 2. Are you presently employed? Yes No If the answer is “Yes,” state the amount of yo ur 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: _________________ ________________________ ________________________________________________________________________ 3. 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, or life insurance payments? Yes No Rent payments, interest or dividends? Yes No REQU EST TO PROCEED IN FORMA PAUPERIS � Administrative�Office�of�the�Courts�( Revised�9�10 �14 )� � [2]�� � � � � F orm�CA�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: _ _________________ ________________________________________________________________________ ________________________________________________________________________ 4. Do you own any cash, or do you have money in a checki ng or savings account? (Include any funds in prison accounts): Yes No If the answer is “Yes,” state the total value of t he items owned: _____________________ 5 . 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: __________ ________________________________________________________________________ ________________________________________________________________________ 6. 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 understand that a false statement or answer to any qu estion in this affidavit 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 perjury when, in a judicial proceeding, he knowingly and willfully makes a false statement material to the issue on point in question b. A person co nvicted of the offense of perjury shall be punished by a fine of not more tha n $1,000 or by imprisonment for not less than one nor more than ten years, or both. O.G.C.A. § 16 -10 -70. _________________________________ _____________ Signature of Plaintiff Date � Administrative�Office�of�the�Courts�( Revised�9�10 �14 )� � [3]�� � � � � F orm�CA�2� VERIFICATION I, ____ ________________________________ _ , do swear and affirm under penalty 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 plaintiff in this action and know the conte nt of the above Request to Proceed in Forma Pauperis. I verify that the answers I have given are true of m y own knowledge, except as to those matters that are stated in it on my information and belief, and as to those 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 Plaintiff Date Sworn to and subscribed before me this _______ day of ______________, 20____. ___________________________________________________ Notary Public o r Other Person Authorized to Administer Oaths Please note that under O.G.C.A. § 42 -12 -5 service of an affidavit in forma pauperis, including all attachments, shall be made upon the court and all named defendants. Failure by the prisoner to comply with this code secti on shall result in dismissal without prejudice of the prisoner’s action. � Administrative�Office�of�the�Courts�( Revised�9�10 �14 )� � [4]�� � � � � F orm�CA�2� CERTIFICATION I hereby certify that the Plaintiff 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 follo wing securities according to the records of said institution: ______________________________________________ _____________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ___________________________________ _________________ Authorized Officer of Institution Date THIS FORM IS TO BE COMPLETE D ONLY BY AN AUTHORIZED INDIVIDUAL AT THE INSTITUTION WHERE THE INMATE PLAINTIFF IS PRESENTLY INCARCE RATED, OR HIS/HER DESIGNEE. NOTE: Please attach a co py of the prisoner’s inmate account of the last 12 months, or the period of incarceration (whichever is less).