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A-18 (5/00)Motion, Affidavit and Order re: Appeal in Forma PauperisPage 1 of 3Name/Address of Attorney or Pro PerTelephone G FPD G Apptd G CJA G Pro Per UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA PLAINTIFF(S), v. DEFENDANT(S).CASE NUMBER: Motion, Affidavit and Order re: Appeal In Forma Pauperis: G 28 U.S.C. 753(f) G 28 U.S.C. 1915 MOTION AND AFFIDAVIT The undersigned , a party in the within action, moves the Court under 28 USC § 1915 for authorization to prosecute an appeal without prepayment of fees and costs or security therefor, and for the preparation of a Court Reporter's transcript at government expense. 1.I believe I am entitled to redress, and the issues which I desire to present on my proposed appeal are the following: a.b.c.2.Because of my poverty I am unable to pay the costs of the proposed appeal proceeding or to give security therefor. I swear that the following responses are true. a.Are you presently employed? G Yes G No. If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer. b.Have you received, within the past twelve months, any income from a business, profession or other form of self- employment, or in the form of rent payments, interest, dividends, or other source? G Yes G No. If the answer is yes, describe each source of income and state the amount received from each during the past twelve months. A-18 (5/00)Motion, Affidavit and Order re: Appeal in Forma PauperisPage 2 of 3c.Are you presently employed in prison?G Yes G No. If yes, state the number of hours you work per week and the hourly rate of pay.d.Do you own any cash or do you have money in a checking or savings account? G Yes G No. If the answer is yes, state the amount of money in each account separately as of six (6) months prior to the date of this affidavit. e.Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? f.In what year did you last file an income tax return? g.Approximately how much income did your last tax return reflect? h.List the persons who are dependent upon you for support and state your relationship to those persons.i.State monthly expenses, itemizing the major items. Signature of Party I declare under penalty of perjury that the foregoing is true and correct. Date Signature of Attorney (Disregard if filed in propria persona) A-18 (5/00)Motion, Affidavit and Order re: Appeal in Forma PauperisPage 3 of 3ORDER (The check mark in the appropriate box indicates the Order made) G The court has considered the motion and the motion is DENIED. The Court certifies that the proposed appeal is not taken in good faith under 28 U.S.C. 1915(a) and is frivolous, without merit and does not present a substantial question within the meaning of 28 U.S.C. 753(f). The Clerk is directed to serve copies of this Order, by United States mail, upon the parties appearing in this cause. DateUnited States District Judge G The court has considered the motion and the motion is GRANTED. It appears to the Court that the proposed appeal is taken in good faith within the meaning of 28 U.S.C. 1915(a). The Court certifies that the proposed appeal is not frivolous, that it presents a substantial question. The within moving party is authorized to prosecute an appeal in forma pauperis to the United States Court of Appeals for the Ninth Circuit without pre-payment of any fees or costs and without giving security therefor. GA transcript is needed to decide the issue presented by the proposed appeal, all within the meaning of 28 U.S.C. 753 (f). The Court Reporter is directed to prepare and file with the Clerk of this Court an original and one copy of a transcript of all proceedings had in this Court in this cause; the attorney for the appellant is advised that a copy of the transcript will be made available to him. The expense of such transcript shall be paid by the United States pursuant to 28 U.S.C. 1915(c) and 753(f). The Clerk is directed to serve copies of this Order, by United States mail, upon the parties appearing in this cause. DateUnited States District Judge