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Derrick's Incarceration

FORMA PAUPERIS
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DOC RULES FOR ADULT INMATES
DOC -- DISCIPLINARY REPORT
DOC INCIDENT REPORT
INITIAL ARP FORM
FIRST STEP RESPONSE
SECOND STEP RESPONSE TO SECRETARY OF DOC
RISK REVIEW FORM
PAROLE
LOCATE INMATE
CLEMENCY APPLICATION / RULES
DOC HEADQUARTERS CONTACT NUMBERS
RISK REVIEW
FURLOUGHS / FUNERALS
PLACEMENT / TRANSFER OF INMATES
WORK RELEASE -- SELECTION -- JAIL / DOC
DOC INSTITUTIONS (PRISONS)
LOUISIANA ACLU COMPLAINT
COURT / JAIL LISTING BY PARISH
DOC ARP (GRIEVANCE) PROCESS
MOTIONS
TITLE 42 U.S.C. 1983
APPELLATE FORMA PAUPERIS
FORMA PAUPERIS
LAWS BEFORE INMATE FILING: CARP /PLRA
ACTUAL BLANK IJR -- PETITION FOR JUDICIAL REVIEW

Number: Section:
vs. 19th Judicial District Court
Parish of East Baton Rouge
State of Louisiana

MOTION TO PROCEED IN FORMA PAUPERIS

COMES NOW, _________________________________________, plaintiff, in the above styled cause and, pursuant to the provisions of C. C. P. Art. 5181 et seq., respectfully moves for leave to proceed in forma pauperis without payment of fees, cost or security given therefore. In accordance with LSA – R.S. 15:1186 et seq, the plaintiff shall be required, when funds exists, to pay an initial partial filing fee of 20% of the average monthly deposits and thereafter prison officials shall be required to forward monthly payments of 20% of the preceding month’s income credited to the plaintiff’s inmate account until the entire filing fee is paid. Plaintiff hereby authorizes the Department of Corrections to withhold and forward to the Clerk of Court the initial and subsequent monthly payments.


Date:_______________________ ____________________________
Signature/DOC #
____________________________
Name of Facility where Housed
____________________________
Address of Facility


AFFIDAVIT IN SUPPORT OF REQUEST
TO PROCEED IN FORMA PAUPERIS

I, _________________________________________, declare that I am the plaintiff in the above entitled case; that in support of my motion to proceed without being required to prepay fees, costs or give security therefor, I state that because of my poverty that I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am entitled to redress.
I further declare that the responses which I have made to the questions and instructions below are true.

1. Are you presently employed: YES ( ) NO (X) INCARCERATED

a. 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. If the answer is no, state the date of last employment and the amount of the salary and wages per month which you received. __________________________________________
__________________________________________________________________________________________________________________________________________________.


2. Have you received within the past twelve months any money from any of the following sources?

a. Business, profession, or form of self-employment (hobby craft sales included)?
YES ( ) NO ( )

b. Rent payments, interest or dividends? YES ( ) NO ( )

c. Pensions, annuities or life insurance payments? YES ( ) NO ( )

d. Gifts of inheritances? YES ( ) NO ( )

e. Any other sources? YES ( ) NO ( )




If the answer to any of the above is yes, describe each source of money and state the amount
received from each during the past 12 months. _______________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Do you own any cash, or do you have any money and/or bonds in a checking or savings account? (Include any funds in prison accounts) YES ( ) NO ( )
If the answer is YES, state the total value of items owned.

Prison Drawing Account $_____________________________

Prison Savings Account:
A. Cash __________________________________

B. Bonds _________________________________

C. Other (specify) ____________________________________________________
________________________________________________________________________________________________________________________________

4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishing and clothing)? YES ( ) NO ( )
If the answer is YES, describe the property and state its approximate value: ________________
________________________________________________________________________________________________________________________________________________________

5. List the persons who are dependent on you for support, state your relationship to those persons, indicate how much you contribute toward their support: _______________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________



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

I understand that a false statement or answer to any question in this affidavit will subject me to penalties for perjury and/or dismissal of my suit. I authorize the Department of Corrections to make payments from my account(s) in accordance with law.


___________________________ ____________________________
Date Signature of Plaintiff

STATEMENT OF ACCOUNT
(Certified Institutional Equivalent)

I hereby certify that ______________________________, inmate number __________,
the plaintiff herein has the following sums of money on account to his/her credit at __________
__________________, the institution where he/she is confined:

Prison Drawing Account: $
Prison Savings Account: $
A. Cash _________________________
B. Bonds ________________________



I further certify that the average monthly deposits for the preceding six months is $_________

(The average monthly deposits are to be determined by adding the deposits made during a given month and dividing the total by the number of deposits made during that month. This is repeated for each of the six months. The average from each of the six months are to be added together and the total is to be divided by six.)


I further certify that the average monthly balance for the prior six months is $______________

(The average monthly balance is to be determined by adding each day’s balance for a given month and dividing that total by the number of days in that month. This is to be repeated for each of the six months. The balance from each of the six months are to be added together and the total is to be divided by six.)


_____________________ ________________________________________
Date Certified Signature of Authorized Officer of Institution &
Title of Institution

STATE OF LOUISIANA
PARISH OF EAST BATON ROUGE


_____________________, being first duly sworn and under oath, presents that he/she has read, signed, and subscribed to the above and states that the information therein is true and correct.

__________________________________
Plaintiff’s Signature
Plaintiff’s D.O.C. # _________________


Subscribed and sworn to before me this _______ day of ______________________, 20 _____.

__________________________________
Notary Public or other person authorized
to administer oaths


STATE OF LOUISIANA
PARISH OF BATON ROUGE

_______________________________, being first duly sworn under oath, did depose and say that he/she is not the attorney or plaintiff; that he/she knows plaintiff; and, knows his/her financial condition, and believes that he/she is unable to pay the costs of court in advance, or as they accrue, or to furnish security therefor.

______________________________
Signature of Affiant



Sworn to and subscribed before me this ________ day of _____________________, 20 ________.



____________________________________
Notary Public or other person authorized
to administer oaths



I CAN VOTE WHEN I AM RELEASED AND I WILL!!!!!