Opinion ID: 1572342
Heading Depth: 1
Heading Rank: 41

Heading: prisoner's motion and affidavit to proceed without prepayment of court costs and fees

Text: I, am a plaintiff/petitioner/appellant in the above-styled action. I have been convicted of a crime and am currently incarcerated for that crime, or I am being held in custody pending extradition or sentencing. Pursuant to § 57.085, Fla. Stat., I hereby apply for leave to proceed in this action without prepayment of court costs and fees. I acknowledge that the custodian or the custodian's designee for my inmate trust account may withdraw funds from my account and transmit these funds to the clerk of the court, as directed by order of the court. These funds will be applied to any court costs or fees that the court requires me to pay in connection with this case. This acknowledgment applies to any institution in which I am or will be confined. I am unable to pay court costs and fees. Under penalty of perjury, I swear or affirm that all statements in this affidavit are true and complete. 1. State your inmate number and the place and address of the institution where you are in prison or in custody. 2. Are you presently employed? Yes () No () a. If yes, state your occupation, the amount of your monthly salary or wages, and your employer's address. b. If no, state the time period of your last employment, your occupation, and the amount of monthly salary or wages received. 3. Have you received within the past twelve months any money from any of the following sources? a. Business, profession, or self-employment? Yes () No () b. Rent, payments, interest, or dividends? Yes () No () c. Pensions, annuities, or life insurance? Yes () No () d. Gifts or inheritances? Yes () No () e. Any other source? Yes () No () If you answered yes to any of the above, describe each source and state amount received from each. 4. Do you own any cash, or do you have money in a checking, savings, or money market account? (Include funds in prison account.) Yes () No () If yes, state the amount of cash owned and the current balance(s) in each checking, savings, or money market account. 5. Do you own any real estate, stocks, bonds, notes, automobiles, or other tangible or intangible thing of value worth more than $100? Yes () No () If yes, describe each item of property and state its approximate value. 6. List the persons who are dependent upon you for support, state their ages and their relationship to you, and indicate how much you contribute toward their support. 7. State the nature and amount of any significant monthly expenses that you must pay, such as mortgage payments or rent. 8. List all of your significant debts, including the name of each person or entity to whom you owe the debt, the total amount owed, and monthly payment, if any. 9. During the past three years, have you been permitted two or more times to proceed without prepayment of court costs or fees in Florida or federal courts or adjudicatory forums, or to intervene in actions in these courts or adjudicatory forums without prepayment of court costs or fees, pursuant to Sections 57.081 or 57.085, Florida Statutes, or 28 U.S.C. § 1915? Yes () No () If yes, list below all suits, actions, claims, proceedings, or appeals that you have brought or intervened in during the past five years in any court or adjudicatory forum. Name of Court, Case Number====- Nature-of--Disposition If necessary, attach additional pages that reflect the required information. Signature of Appellant/ Plaintiff/Petitioner State of Florida County of= Sworn to and subscribed before me on .....(date)..... by ......(name)...... Notary Public State of Florida (Print, Type, or Stamp Commissioned Name Of Notary Public) Personally known OR Produced Identification Type of Identification Produced