Ro!:>t vi- we rfFILED28APR'1515:Q4USDC·CRP 

UNITED STATES DISTRICT COURT 

DISTRICT OF OREGON 

PORTLAND DIVISION 

3 '15 CV- 7 15- ~-·- ST 

Civil Case No. 

(to be assigned by Clerk of the Court) 

(Enter full name of plaintiff(s)) APPLICATION TO PROCEED 

IN FORMA PAUPERIS 

Plaintiff( s ), 

v. 

(Enter full name of ALL defendant(s)) 

I 5 b 0-?-f-.1 C. ov) 

Defendant(s). 

I, f< e7 l.; l' v+ \IV'( J (- , declare that I am the plaintiff in the above-entitled proceeding; 

that, in support of my request to proceed without prepayment of fees under 28 U.S. C. § 1915, I declare than 

I am unable to pay the fees for these proceedings or give security therefor and that I am entitled to the relief 

sought in the complaint. 

1. 

In support of this application, I answer the following questions: 

Are you currently incarcerated? 0Yes~No 

If "Yes" state the place of your incarceration: 

If "Yes" and you are filing a civil action, have the institution fill out the Certificate portion of 

this application and attach a certified copy of your prison trust account showing transactions 

for the past six (6) months. 

2. Are you currently employed? DYes (}g No 0Self-employed 

a. If the answer is "Yes," state: 

Employer's name:-------------------------

Employer's address:------------------------

Amount of take-home pay or wages: $ _____ per ____ (specify pay period) 

Revised August 6, 2010 

Page 1 USDC - Oregon 

Case 3:15-cv-00715-ST Document 1 Filed 04/28/15 Page 1 of 5
.. 

b. If the answer is "No," state: 

Name oflast employer:------------------------

Address oflast employer:----------------------

Date of last employment: -----------------------

Amount of take-home salary or wages: $ _____ per ____ (specify pay period) 

3. Is your spouse or significant-other employed? DYes DNo D Self-employed DNot applicable 

If the answer is "Yes," state: 

Employer's name:---------------------------

Employer's address:-------------------------

Amount of take-home pay or wages: $ _____ per _____ (specify pay period) 

4. In the past 12 months have you received any money from any of the following sources? 

a. Business, profession or other self-employment DYes ~No 

b. 

If "Yes," state: Amount received: $ ---------------- Amount expected in future: $-------------------

Rent payments, interest, or dividends 

If "Yes," state: Amount received: 

DYes ~No 

$ _______________ _ 

Amount expected in future: $------------------

c. Pensions, annuities, or life insurance payments DYes ~No 

If"Yes," state: Amount received: $ --------------- Amount expected in future: $ ---------------

d. Disability or workers compensation payments g)Yes DNo 

If"Yes," state: Amount received: $ 7ot:l ~~~-------

Amount expected in future: $ -----------------

e. Gifts or inheritances DYes [KJNo 

If "Yes," state: Amount received: $ _______________ _ 

Amount expected in future: $ -------------------

f. Any other sources DYes KJNo 

If "Yes," state: Source: 

Amount received: $ ________________ _ 

Amount expected in future: $ ________ _ 

Revised August 6, 2010 

Page 2 USDC - Oregon 

Case 3:15-cv-00715-ST Document 1 Filed 04/28/15 Page 2 of 5
5. Do you have cash or checking or savings accounts? 

(including prison trust accounts)? 

If 11Y es, 11 state the total amount:.'-c.;;.5_o_O _____ _ 

KJYes 0No 

6. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or 

7. 

other valuable property? g]Yes 0No 

If 11Yes, 11 describe the asset(s) and state the value of each asset listed . . v 

Do you have any other assets? DYes rxJNo 

If 11Y es, 11 list the asset(s) and state the value of each asset listed. 

8. Do you have a~1ousi~ transportation, utilities, or loan payments, or other regular monthly 

expenses? 00 Yes UNo 

rovide the amount of the monthly expense. 

Zc;O 

00 

9. List the persons (or, if under 18, initials only) who are dependent on you for support, state your 

relationship to each person and indicate how much you contribute to their support. 

Revised August 6, 2010 

Page 3 USDC - Oregon 

Case 3:15-cv-00715-ST Document 1 Filed 04/28/15 Page 3 of 5
' 

10. Do you have any debts or financial obligations? ~Yes 0No 

If "Yes," describe the amounts owed and to whom they are payable. 

<.ved.'f c ... vc[f 11 >ou 

If I am incarcerated, I hereby authorize the agency having custody of me to collect from my 

trust account and forward to the Clerk of the United States District Court payments toward the full 

filing fee of $350.00 for a prisoner civil rights complaint in accordance with 28 U.S.C. § 1915(b). 

I declare under penalty of perjury that the above infonnation is true and correct. 

Y 128( 2-ofS 

DATE 

Revised August 6, 2010 

Page 4 

SIGNATURE OF APPLICANT 

R o~evt-. L.fe_ weJJPRINTED NAME OF APPLICANT 

USDC - Oregon 

Case 3:15-cv-00715-ST Document 1 Filed 04/28/15 Page 4 of 5
\ 

CERTIFICATE 

(To be completed by the institution of incarceration.) 

I certify that the applicant named herein has the sum of$ _____ on account to his/her credit 

at-----------------(name of institution). I further certify that during the past 

six months the applicant's average monthly balance was$ ____ . I further certify that during the past 

six months the average of monthly deposits to the applicant's account was $ ___ _ 

I have attached a certified copy of the applicant's trust account statement showing the transactions 

for the past six months. 

DATE 

Revised August 6, 2010 

Page 5 

SIGNATURE OF AUTHORIZED OFFICER 

USDC - Oregon 

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