FIL£D24 FEB '1614:421.JSDC-(JRP 

UNITED STATES DISTRICT COURT 

DISTRICT OF OREGON 

PORTLAND DIVISION 

(to be assigned by Clerk of the Court) 

(Enter full name of plaintiff(s)) 

Plaintiff(s), 

v. 

Defendant(s). 

• 

APPLICATION TO PROCEED 

IN FORMA PAUPERIS 

I, Mtiwldfta #1/%//..e , declare that I am the plaintiff in the above-entitled proceeding; 

that, in support of my request to proceed without prepayment offees 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. 

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

1. Are you currently incarcerated? 0Yes,g( 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? D Yes~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 

SI 

Case 3:16-cv-00341-SI Document 2 Filed 02/24/16 Page 1 of 6
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? 0Yes 0No D Self-employed~ot 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 0Yes ~o 

b. 

c. 

d. 

e. 

f. 

If "Yes," state: Amount received: $ ----------

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

Rent payments, interest, or dividends 0Yes ~o 

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

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

Pensions, annuities, or life insurance payments 0Yes ~o 

If "Yes," state: Amount received: 

Amount expected in future: 

Disability or workers compensation payments 

If "Yes," state: Amount received: 

Amount expected in future: 

Gifts or inheritances 

If "Yes," state: Amount received: 

Amount expected in future: 

Any other sources 

If"Yes," state: Source: 

Amount received: 

Amount expected in future: 

$ _________ _ 

$ < 

0Yes'®'."No 

$ _________ _ 

$ < 

0Yesii'No 

$ _________ _ 

$---~------

0Yes ~o 

$ _________ _ 

$ _________ _ 

Revised August 6, 2010 

Page2 USDC - Oregon 

Case 3:16-cv-00341-SI Document 2 Filed 02/24/16 Page 2 of 6
5. 

6. 

7. 

8. 

Do you have cash or checking or savings accounts? 

(including prison trust accounts)? 

If "Yes," state the total amount: ~~~~~~~~-

0Yes !;3No 

Do you own any real estate, stocks, bon~urities, other financial instruments, automobiles or 

other valuable property? OYes,.esJNo 

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

Do you have any other assets? 0Yes~o 

If "Yes," list the asset(s) and state the value of each asset listed. 

Do you have anx..,housi~ansportation, utilities, or loan payments, or other regular monthly 

expenses? LJYesLj-No 

If "Yes," describe and provide the amount of the monthly expense. 

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 3:16-cv-00341-SI Document 2 Filed 02/24/16 Page 3 of 6
, 

10. Do you have any debts or financial obligations? 0Yes EfNo 

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

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. 

~J_;;~c!ZCJ/~ DATE SIGNATURE ~4?1~ OF APPLICANT 

Revised August 6, 2010 

Page4 

7//e:t~_/£Y(_ ff&ile 

PRINTED NAME OF APPLICANT 

USDC - Oregon 

Case 3:16-cv-00341-SI Document 2 Filed 02/24/16 Page 4 of 6
AO 240 (Rev. 07/I 0) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Fonn) 

UNITED STATES DISTRICT COURT 

Jfl, 'c ~ct f !Jk)ftlflc;{//eoREGON ~r / {~1~nj._/( Plaintiff/Petitioner 

v. 

MULTNOMAH COUNTY COURTS 

Defendant/Respondent 

for the 

) 

) 

) 

) 

) 

Civil Action No. 

APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS 

(Short Form) 

I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings and 

that I am entitled to the relief requested. 

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

1. Ifincarcerated. I am being held at:---·------ ----·--------

! f employed there, or have an account in the institution, I have attached to this document a statement certified by the 

appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any 

institutional account in my name. I am also submitting a similar statement from any other institution where I was 

incarcerated during the last six months. 

2. If not incarcerated. Ifl am employed, my employer's name and address are: 

I am unemployed 

My gross pay or wages are: $ , and my take-home pay or wages are: $ ------ _______ per 

(specify pay period) 

3. Other Income. In the past 12 months, I have received income from the following sources (check all that appl;): 

(a) Business, profession, or other self-employment 0 Yes t¥f No 

(b) Rent payments, interest, or dividends 0 Yes ~No 

(c) Pension, annuity, or life insurance payments 0 Yes t¥f No 

(d) Disability, or worker's compensation payments 0 Yes )('No 

( e) Gifts, or inheritances 0 Yes !if No 

(f) Any other sources 0 Yes KNo 

ff you answered "Yes" to any question above, di!scribe below or on separate pages each source of money and 

state the amount that you received and what you expect to receive in the future. 

Case 3:16-cv-00341-SI Document 2 Filed 02/24/16 Page 5 of 6
AO 240 (Rev. 07110) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Fann) 

4. Amount of money that I have in cash or in a checking or savings account: $ ________ 0_._0_0_ . 

5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or 

thing of value that I own, including any item of value held in someone else's name (describe the property and its approximate 

value): 

0 

6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide 

the amount of the monthly expense): 

whatever I have 

7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship 

with each person, and how much I contribute to their support: 

8. Any debts or financial obligations (describe the amounts owed and to whom they are payable): 

Declaration: I declare under penalty of perjury that the above information is true and understand that a false 

statement may result in a dismissal of my claims. 

Date: %Jr 2-3 ~UJ/( J /t7 

Printed name 

Case 3:16-cv-00341-SI Document 2 Filed 02/24/16 Page 6 of 6