Florida Motion and Affidavit to Proceed in Forma Pauperis

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Florida Motion and Affidavit to Proceed in Forma Pauperis Powered By Docstoc
					                                       IN THE SUPREME COURT OF FLORIDA

                                       CASE NUMBER:       -~-----:=~~---




      Petitioner/Appellant

vs.




MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS/AFFIDAVIT              \

         OF INDIGENCY BY PETITIONER/APPELLANT


      Petitioner/Appellant                                        in propria persona,
respectfully moves this Court for an order permitting himlher to proceed in forma
pauperis. In support hereof petitioner/appellant submits a financial affidavit of
indigency as required by section 57.081 or 57.085(2), Florida Statutes (1997).

                                        Respectfully submitted,

                             FINANCIAL AFFIDAVIT

      I,                               hereby depose and say that I am unable to pay
court costs and fees and submit the following information for review: AGE:
DATE OF BIRTH:         U/3o/'6  MARITAL STATUS: Married _ Separated
Divorced _ Single _ LIST DEPENDENTS, THEIR NAMES, AND AGES:
                                                                                =
II. FINANCIAL CONDITION:

      Affiant's Gross Income: Weekly       ----lieo'---   Bi-Weekly $_ _ Monthly


     Spouse's Gross Income: Weekly $_ _ Bi-Weekly $_ _ Monthly

     Own Home: Yes _ _ No _ _ Monthly Mortgage Payments $                           _
     ~alueof~eaIProperty~~ned $~~~~~~~~~~~~~~~

     Own Automobile: Yes _ _ No ~_ Monthly Payments $                               _
     ~ alue   of Automobile: $                  Year/Make:      ~-~-~~~~~




     Value of Personal Property Owned (boats, furniture, stocks, jewelry,
     etc.):
              List all tangible property ~ith a value over $100.00
                     Item                              $ Value




     List creditor and the amount owed to each creditor:




                                          2

Amount of cash held by petitioner/appellant: $      -.;;:~--------




Balance of checking account:

Balance of savings account: $
                             --------------------
Amount held in money-market (stocks, bonds, other tangible personal
property): $~~~ ___

The following applies only to persons who are incarcerated:
My inmate number is: ql~ %'"16

Amount currently held in the petitioner's inmate trust account: $       ---=~-



Attach photocopy of inmate's trust account records for the proceeding six (6)

months or for appellants/petitioner's incarceration, whichever period is

shorter.


Are you presently employed in an inmate work program within the

Department of Corrections? Yes             No       V

If the answer is "YES" complete the following:

Wages earned: $           Name and Address of employer:                       _



If answer is "NO" state the date of your last employment and the salary and

wages earned per month. Date:                 Wages earned:


Are you presently employed in a work release program? Yes _             No

If answer is "YES" complete the following: Wages earned: $                    _

Name and address of employer:



If answer is "NO" state the date of your last employment and the salary and
wages earned per month: Date                 Wages earned: $- - - - - -

I certify that I have         have not        been adjudicated indigent
under section 57.081, 57.085 or 28 U.S.C. s 1915. If your answer is "YES"
and it occurred twice in the preceding three (3) years, you are required to list
each suit, action, claim, proceeding, or appeal which you have intervened in

                                    3
      1. ~1ll..Jl.lLL!Ji£l;11..£i.U....l.l-'L~~~~~~~~--J::I.~~LL!L~~~~~~'.Jt.LLf4/J.
      2.
          --------------------------
      3.
 - - - - - - - - - - - - - - - - - - - - - - - - - -
      Attach extra sheet(s) if necessary.



      Under penalties of perjury, I declare that I have read the following
 (document) and that the facts stated in it are true. (92.525(2) Fla. Stat.
 (1995))

      Dated this   --1-- _ _   day of   --71--..:.-..;....;;.+-----'   20_, at ---'--~-ll...I:-.-~lI-----Z--'
 Florida.

                                                             Address:
       Signature of Petitioner/Appellant



ONLY NOTARIZE, IF YOU DO NOT SIGN "UNDER PENALITIES OF
PERJURY"
Sworn to and subscribed before me this
_ _ _ day of                   , 20_ _

                                                      My Commission Expires: - - - - -


                               CERTIFICATE OF SERVICE

      I certify that a copy hereof has been furnished to                                             _


(insert name(s) and addressees) of attorney(s) party(ies) in the case) by mail
 this        day of                                      , 20_



                                                           Signature of Petitioner/Appellant

                                                       4
                        IN THE SUPREME COURT OF FLORIDA


                                                                                                      Supreme Court Case No.    ~-----.;;..~




                                                                                                      Lower Tribunal Case No.
vs.




                CER~IFICATE        REGARDING INMATE ACCOUNT

                        (Department of Corrections' Represerltative:

                        Please sign applicable portion of certificate)


      I -"'.. . y-.......... that petitioner does not have a bank account within the institution in
which he                       is confined.


                                                                                       Signature of Authorized Officer of Institution


                                                                                       Address:

                                                                                       Date:

-or­

                                    has the sum of $
                           . . . . , _ ... ,,1,.. ... ,1,.. .... 'on account to his or
                                                                     ...... _   ....




              ~~~:......:..-~--=-=-----
                                                 Correctional Institution where he or
she is confined. I further certify that during the last six months the petitioner's
average daily balance was               (}            . (Attach a statement of the
inmate's bank account for last six months.)
                                                                                           /\                 .
                                                                                          ::;.        F~
                                                                                       Signature of Authorized Officer of Institution

                                                                                       Name: :::J. flt~L .-'t:-IC

                                                                                       Institution: !J&M:Li-fn       {!. T'~

                                                                                       Address:      to ~ So?> b kJ   Y 19 r"'I. ~,

                                                                                                    -0-~tl1bJ= /2-[. .3 ~() or.:t.
                                                                                       Date:       -5 --t 2-'bq
                                                                                                  5
                        FLORIDA DEPARTMENT OF CORRECTIONS                    05/12/09
IBSR176   (90)            INITIAL PAYMENT FOR FILE FEE                       13:46:09
                                FOR: 05/12/2009                              PAGE   1

DC #      924820   INMT NAME     MCLEOD, STEVEN A.            CURR BAL   $          0.00

HOLDS     $      0.00 LIENS      $ 1,693.60                  SPENDABLE   $          0.00


 DATE   RANGE           MONTHLY AVERAGE DEPOSITS         MONTHLY AVERAGE BALANCES
11/13   - 12/12              $         0.00                        $         0.00
12/13   - 01/11              $         0.00                        $         0.00
01/12   - 02/10              $         0.00                        $         0.00
02/11   - 03/12              $         0.00                        $         0.00
03/13   - 04/11              $         0.00                        $         0.00
04/12   - 05/11              $         0.00                        $         0.00

AVERAGE OVER 6 MONTHS          DEPOSITS     $     0.00
                               BALANCES     $     0.00

CALCULATED INITIAL PAYMENT : $            .0.00
                                                       FLORIDA DEPARTMENT OF CORRECTIONS                                                 05/05/09
IBSR140 (74)                                              TRUST FUND ACCOUNT STATEMENT                                                   13:30:34
                                                          FOR: 11/05/2008 - 05/05/2009                                                   PAGE     1
ACCT NAME: MCLEOD, STEVEN A.                  ACCT#: 924820
      BED: 12214L                              TYPE: INMATE TRUST
     PO BOX:

                                                                                                  BEGINNING BALANCE 11/05/08                 $0.00
               POSTED                             REFERENCE
               DATE       NBR        TYPE           NUMBER       FAC    REMITTER/PAYEE           +/­        AMOUNT          BALANCE
               -------­   --­   --------------­   -----------­   - -­   ------------------------­ - - ­   ---------­   --------------­
               11/13/08 231 LEGAL COPIES WD       20081106       000                                -          $0.00             $0.00
                            LIEN CREATED          - 11/13/2008   20081106
               11/20/08 227 LEGAL COPIES WD       20081112       000                                -          $0.00             $0.00
                            LIEN CREATED          - 11/20/2008   20081112
               11/20/08 234 LEGAL POSTAGE W       11142008       000                                -          $0.00             $0.00
                            LIEN CREATED          - 11/20/2008   11142008
               11/25/08 174 LEGAL POSTAGE W       20081119       000                                -          $0.00             $0.00
                            LIEN CREATED          - 11/25/2008   20081119
               11/25/08 174 LEGAL POSTAGE W       20081119A      000                                -          $0.00             $0.00
                            LIEN CREATED          - 11/25/2008   20081119A
               11/26/08 144 LEGAL POSTAGE W       20081107       000                                -          $0.00             $0.00
                            LIEN CREATED          - 11/26/2008   20081107
               11/26/08 192 LEGAL POSTAGE W       20081120       000                                -          $0.00             $0.00
                            LIEN CREATED          - 11/26/2008   20081120
               12/15/08 236 LEGAL POSTAGE W       120308         000                                -          $0.00             $0.00
                            LIEN CREATED          - 12/15/2008   120308
               12/16/08 199 LEGAL COPIES WD       120208         000                                -          $0.00             $0.00
                            LIEN CREATED          - 12/16/2008   120208
               12/24/08 187 LEGAL POSTAGE W       121208         000                                -          $0.00             $0.00
                            LIEN CREATED          - 12/24/2008   121208
               01/08/09 290 LEGAL POSTAGE W       20081218       000                                .­         $0.00             $0.00
                            LIEN CREATED          - 01/08/2009   20081218
               01/08/09 348 LEGAL POSTAGE W       12232008       000                                -          $0.00             $0.00
                            LIEN CREATED          - 01/08/2009   12232008
               01/08/09 386 LEGAL COPIES WD       20081222       000                                -          $0.00
                            LIEN CREATED                                                                                         $0.00
                                                  - 01/08/2009   20081222
               01/08/09 386 LEGAL COPIES WD       20081217       000                                -          $0.00             $0.00
                            LIEN CREATED          - 01/08/2009   20081217
               01/09/09 188 LEGAL POSTAGE W       20081223       000                                           $0.00             $0.00
                            LIEN CREATED          - 01/09/2009   20081223
               01/09/09 188 LEGAL POSTAGE W       20081223A      000                                -          $0.00             $0.00
                            LIEN CREATED          - 01/09/2009   20081223A
               01/09/09 218 LEGAL COPIES WD       20081229       000                                -          $0.00             $0.00
                            LIEN CREATED          - 01/09/2009   20081229
               01/15/09 198 LEGAL POSTAGE W       12.30.08       000                                -          $0.00             $0.00
                            LIEN CREATED          - 01/15/2009   12.30.08
               01/15/09 198 LEGAL POSTAGE W       12.31.08       000                                -          $0.00             $0.00
                            LIEN CREATED          - 01/15/2009   12.31.08
               01/15/09 208 LEGAL POSTAGE W       20081230       000                                -          $0.00             $0.00
                            LIEN CREATED          - 01/15/2009   20081230
               01/20/09 129 LEGAL POSTAGE W       20081216       000                                -          $0.00
                            LIEN CREATED                                                                                         $0.00
                                                  - 01/20/2009   20081216
               01/21/09 126 LEGAL COPIES WD       20090113       000                                -          $0.00             $0.00
                            LIEN CREATED          - 01/21/2009   20090113
                                                       FLORIDA DEPARTMENT OF CORRECTIONS                                             05/05/09
IBSR140 (74)                                              TRUST FUND ACCOUNT STATEMENT                                               13:30:34
                                                          FOR: 11/05/2008 - 05/05/2009                                               PAGE     2
ACCT NAME: MCLEOD, STEVEN A.                  ACCT#: 924820
      BED: 12214L                              TYPE: INMATE TRUST
     PO BOX:

               POSTED                             REFERENCE
               DATE       NBR       TYPE            NUMBER       FAC    REMITTER/PAYEE           +/­      AMOUNT         BALANCE
               -------­   --­   --------------­   -----------­   - -­   ------------------------­ --­   ---------­ --------------­
               01/21/09 126 LEGAL COPIES WD       20090116       000                               -         $0.00           $0.00
                            LIEN CREATED          - 01/21/2009   20090116
               01/29/09 228 LEGAL POSTAGE W       20090122       000                               -         $0.00           $0.00
                            LIEN CREATED          - 01/29/2009   20090122
               01/29/09 228 LEGAL POSTAGE W       20090123       000                               -         $0.00           $0.00
                            LIEN CREATED          - 01/29/2009   20090123
               02/11/09 340 LEGAL COPIES WD       20090203       000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/11/2009   20090203
               02/11/09 340 LEGAL COPIES WD       20090206       000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/11/2009   20090206
               02/13/09 133 LEGAL COPIES WD       012109         000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/13/2009   012109
               02/13/09 133 LEGAL COPIES WD       012209         000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/13/2009   012209
               02/13/09 133 LEGAL COPIES WD       012309         000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/13/2009   012309
               02/19/09 134 LEGAL POSTAGE W       20090202       000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/19/2009   20090202
               02/19/09 134 LEGAL POSTAGE W       20090205       000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/19/2009   20090205
               02/19/09 179 LEGAL POSTAGE W       02132009       000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/19/2009   02132009
               02/24/09 227 LEGAL COPIES WD       20090213       000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/24/2009   20090213
               02/24/09 227 LEGAL COPIES WD       20090213A      000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/24/2009   20090213A
               02/26/09 210 LEGAL POSTAGE W       20090220       000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/26/2009   20090220
               02/26/09 210 LEGAL POSTAGE W       20090209       000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/26/2009   20090209
               02/26/09 210 LEGAL POSTAGE W       20090209A      000                               -         $0.00           $0.00
                            LIEN CREATED          - 02/26/2009   20090209A
               03/05/09 128 ID CARDS WD           021809         000                               -         $0.00           $0.00
                            LIEN CREATED          - 03/05/2009   021809
               03/05/09 128 ID CARDS WD           021709         000                               -         $0.00           $0.00
                            LIEN CREATED          - 03/05/2009   021709
               03/05/09 230 LEGAL POSTA.GE W      20090225       000                               -         $0.00           $0.00
                            LIEN CREATED          - 03/05/2009   20090225
               03/05/09 230 LEGAL POSTAGE W       20090227       000                               -         $0.00           $0.00
                            LIEN CREATED          - 03/05/2009   20090227
               03/11/09 177 LEGAL COPIES WD       030609         000                               -         $0.00           $0.00
                            LIEN CREATED          - 03/11/2009   030609
               03/12/09 123 LEGAL COPIES WD       22709          000                               -         $0.00           $0.00
                            LIEN CREATED          - 03/12/2009   22709
               03/12/09 151 LEGAL POSTAGE W       03032009       000                               -         $0.00           $0.00
                            LIEN CREATED          - 03/12/2009   03032009
                                                         FLORIDA DEPARTMENT OF CORRECTIONS                                             05/05/09
IBSR140 (74)                                                TRUST FUND ACCOUNT STATEMENT                                               13:30:34
                                                            FOR: 11/05/2008 - 05/05/2009                                               PAGE     3
ACCT NAME: MCLEOD, STEVEN A.                  ACCT#: 924820
      BED: 12214L                              TYPE: INMATE TRUST
     PO BOX:

               POSTED                              REFERENCE
               DATE       NBR       TYPE             NUMBER       FAC    REMITTER/PAYEE           +/-       AMOUNT        BALANCE
               --------   ---   ---------------   ------------    - --   ------------------------- ---   ---------- ---------------
               03/25/09 148 LEGAL COPIES WD 20090320              000                               -         $0.00           $0.00
                            LIEN CREATED    - 03/25/2009          20090320
               03/26/09 223 LEGAL POSTAGE W 031309                000                               -         $0.00            $0.00
                            LIEN CREATED    - 03/26/2009          031309
               04/14/09 176 LEGAL COPIES WD 20090403              000                               -         $0.00            $0.00
                            LIEN CREATED    - 04/14/2009          20090403
               04/15/09 168 LEGAL POSTAGE W 040209                000                               -         $0.00            $0.00
                            LIEN CREATED    - 04/15/2009          040209
               04/16/09 127 LEGAL COPIES WD 040309                000                               -         $0.00            $0.00
                            LIEN CREATED    - 04/16/2009          040309
               04/24/09 291 LIEN PAYMENT    030509128011          000                               -         $0.00            $0.00
                            ID CARDS WD     - 03/05/2009          021709
               04/24/09 292 LIEN PAYMENT    030509128010          000                               -         $0.00            $0.00
                            ID CARDS WD     - 03/05/2009          021809
               04/24/09 316 LEGAL COPIES WD 2053412               000                               -         $0.00            $0.00
                            LIEN CREATED    - 04/24/2009          2053412
               04/24/09 316 LEGAL COPIES WD 2053413               000                               -         $0.00            $0.00
                            LIEN CREATED    - 04/24/2009          2053413
               04/29/09 174 LEGAL COPIES WD 042209                000                                -        $0.00            $0.00
                            LIEN CREATED    - 04/29/2009          042209

                                                                                                     ENDING BALANCE 05/05/09               $0.00
LIEN                                              LIEN        AMOUNT       AMOUNT
DATE       TYPE OF LIEN                           FACL       OF LIEN   STILL OWED

SUMMARY    LEGAL POSTAGE                                     $104.46      $104.46
SUMMARY    LEGAL COPIES                                      $284.70      $284.69
SUMMARY    MEDICAL CO-PAYMENT                                  $8.00        $8.00
SUMMARY    STATE PRISON LITIGATION                           $806.09      $526.09
11/13/08   LEGAL COPIES                            000         $3.45        $3.45
11/20/08   LEGAL COPIES                            000         $8.25        $8.25
11/20/08   LEGAL POSTAGE                           000         $4.76        $4.76
11/25/08   LEGAL POSTAGE                           000         $1.65        $1.65
11/25/08   LEGAL POSTAGE                           000        $24.45       $24.45
11/26/08   LEGAL POSTAGE                           000         $1.74        $1.74
11/26/08   LEGAL POSTAGE                           000         $6.43        $6.43
12/15/08   LEGAL POSTAGE                           000        $10.50       $10.50
12/16/08   LEGAL COPIES                            000        $41.55       $41.55
12/24/08   LEGAL POSTAGE                           000         $0.59        $0.59
                                                      FLORIDA DEPARTMENT OF CORRECTIONS   05/05/09
IBSR140 (74)                                             TRUST FUND ACCOUNT STATEMENT     13:30:34
                                                         FOR: 11/05/2008 - 05/05/2009     PAGE     4
ACCT NAME: MCLEOD, STEVEN A.                ACCT#: 924820
      BED: I2214L                            TYPE: INMATE TRUST
     PO BOX:

LIEN                                         LIEN          AMOUNT       AMOUNT
DATE       TYPE OF LIEN                      FACL         OF LIEN   STILL OWED
-------­   -----------------------------­    - - -­   ----------­   ----------­
01/0S/09   LEGAL COPIES                        000          $S.40         $S.40
01/08/09   LEGAL COPIES                        000          $0.90         $0.90
01/08/09   LEGAL POSTAGE                       000          $2.10         $2.10
01/08/09   LEGAL POSTAGE                       000          $3.55         $3.55
01/09/09   LEGAL POSTAGE                       000          $0.42         $0.42
01/09/09   LEGAL COPIES                        000         $42.60        $42.60
01/09/09   LEGAL POSTAGE                       000          $0.42         $0.42
01/15/09   LEGAL POSTAGE                       000         $13.97        $13.97
01/15/09   LEGAL POSTAGE                       000          $0.59         $0.59
01/15/09   LEGAL POSTAGE                       000          $0.59         $0.59
01/20/09   LEGAL POSTAGE                       000          $0.42         $0.42
01/21/09   LEGAL COPIES                        000          $9.45         $9.45
01/21/09   LEGAL COPIES                        000          $1.50         $1.50
01/29/09   LEGAL POSTAGE                       000          $3.24         $3.24
01/29/09   LEGAL POSTAGE                       000          $7.71         $7.71
02/11/09   LEGAL COPIES                        000         $43.50        $43.50
02/11/09   LEGAL COPIES                        000          $3.00         $3.00
02/13/09   LEGAL COPIES                        000          $0.90         $0.90
02/13/09   LEGAL COPIES                        000          $1.65         $1.65
02/13/09   LEGAL COPIES                        000         $31.65        $31.65
02/19/09   LEGAL POSTAGE                       000          $9.12         $9.12
02/19/09   LEGAL POSTAGE                       000          $8.05         $8.05
02/19/09   LEGAL POSTAGE                       000          $9.89         $9.89
02/24/09   LEGAL COPIES                        000         $37.50        $37.50
02/24/09   LEGAL COPIES                        000          $2.55         $2.55
02/26/09   LEGAL POSTAGE                       000          $1.68         $1.68
02/26/09   LEGAL POSTAGE                       000          $5.20         $5.20
02/26/09   LEGAL POSTAGE                       000          $1.68         $1.68
03/05/09   LEGAL POSTAGE                       000          $1.93         $1.93
03/05/09   LEGAL POSTAGE                       000          $7.46         $7.46
03/11/09   LEGAL COPIES                        000          $0.60         $0.60
03/12/09   LEGAL COPIES                        000          $4.50         $4.50
03/12/09   LEGAL POSTAGE                       000          $5.80         $5.80
03/13/09   FEDERAL PRISON LITIGATION           215        $350.00       $350.00
03/25/09   LEGAL COPIES                        000          $1.80         $1.80
03/26/09   LEGAL POSTAGE                       000          $3.70         $3.70
04/14/09   LEGAL COPIES                        000          $2.70         $2.70
04/15/09   LEGAL POSTAGE                       000          $0.42         $0.42
04/16/09   LEGAL COPIES                        000          $0.60         $0.60
04/24/09   LEGAL COPIES                        000          $0.30         $0.30
                                       FLORIDA DEPARTMENT OF CORRECTIONS   05/05/09
IBSR140 (74)                              TRUST FUND ACCOUNT STATEMENT     13:30:34
                                          FOR: 11/05/2008 - 05/05/2009     PAGE     5
ACCT NAME: MCLEOD, STEVEN A.   ACCT#: 924820
      BED: I2214L               TYPE: INMATE TRUST
     PO BOX:

LIEN                            LIEN        AMOUNT       AMOUNT
DATE       TYPE OF LIEN         FACL       OF LIEN   STILL OWED
                                       ----------­   ----------­
04/24/09   LEGAL COPIES          000         $0.45         $0.45
04/29/09   LEGAL COPIES          000         $1.95         $1.95

				
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Description: Florida Motion and Affidavit to Proceed in Forma Pauperis document sample