Opinion
CIVIL ACTION NO. 5:07cv34-DCB-MTP, APPEAL NO. _________.
May 21, 2007
ORDER
Upon consideration of the appeal to the United States Court of Appeals for the Fifth Circuit filed by the plaintiff/petitioner in the above entitled action, the court notes that the plaintiff/petitioner failed to pay the appeal fee in the amount of $455.00 or to complete an application to proceed in forma pauperis. Accordingly, it is hereby
ORDERED:
1. That within 20 days of the entry of this order the plaintiff/petitioner shall file a completed application for leave to proceed in forma pauperis or pay the required appeal filing fee of $455.00.
2. That the Clerk shall mail the attached in forma pauperis application to the plaintiff/petitioner at his last known address.
Failure to advise this court of a change of address or failure to comply with any order of this court will be deemed as a purposeful delay and contumacious act by the plaintiff/petitioner and may result in the denial of in forma pauperis status. Form 4 of Federal Rules of Appellate Procedure APPEAL NO. ______________
UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF MISSISSIPPI WESTERN DIVISION FREDERICK HAMILTON BANKS Petitioner v. CIVIL ACTION NO. 5:07cv34DCB-MTP CONSTANCE REECE RespondentMOTION TO PROCEED IN FORMA PAUPERIS
I, __________________________________________, declare that I am the plaintiff in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under 28 U.S.C. § 1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in the complaint. Signed: _________________________________________________ Date: ______________________ _________________________________________________________________INSTRUCTIONS
Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a questions is "0," "none," or "not applicable (N/A)," write in that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with you name, your case's docket number, and the question number.AFFIDAVIT IN SUPPORT OF MOTION
I swear or affirm under penalty of perjury that, because of my poverty, I cannot prepay the docket fees of my appeal or post a bond for them. I believe I am entitled to redress. I swear or affirm under penalty of perjury under United States laws that my answers on this form are true and correct. ( 28 U.S.C. § 1746; 18 U.S.C. § 1621)Signed: ______________________________
Date: ________________________________
My issues on appeal are:
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____________________________________________________ DATES OF GROSS EMPLOYER ADDRESS EMPLOYMENT MONTHLY PAY DATES OF GROSS EMPLOYER ADDRESS EMPLOYMENT MONTHLY PAY FINANCIAL AMOUNT YOUR INSTITUTION TYPE OF ACCOUNT AMOUNT YOU HAVE SPOUSE HAS If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account.
1. For both you and your spouse estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise. Income source: Average monthly Amount expected amount during the next month past 12 months You You Employment $____ $____ Self-employment $____ $____ Income from real property $____ $____ such as rental income) Interest and dividends $____ $____ Gifts $____ $____ Alimony $____ $____ Child support $____ $____ Retirement (such as social $____ $____ security pensions, annuities, insurance) Disability (such as social $____ $____ security insurance payments) Unemployment payments $____ $____ Public-assistance (such as welfare) $____ $____ Other (specify): ____________________ $____ $____ Total monthly income: $____ $____ 2. List your employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) 3. List your spouse's employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) 4. How much cash do you and your spouse have? $_______ Below, state any money you or your spouse have in bank accounts or in any other financial institution. 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings. HOME (VALUE) OTHER REAL ESTATE (VALUE) OTHER ASSETS (VALUE) MOTOR VEHICLE # 1 VALUE: ____________________ MAKE YEAR: ___________________ MODEL: __________________ REGISTRATION #: __________________ MOTOR VEHICLE # 2 VALUE: ____________________ MAKE YEAR: ___________________ MODEL: __________________ REGISTRATION #: __________________ 6. State every person, business, or organization owing you or your spouse money, and the amount owed. PERSON OWING YOU OR AMOUNT OWED AMOUNT OWED YOUR SPOUSE MONEY TO YOU TO YOUR SPOUSE 7. State the persons who rely on you or your spouse for support. NAME RELATIONSHIP AGE 8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. You Your Spouse Rent or home-mortgage payment $____ $____ (include lot rented for mobile home) Are real-estate taxes included? [ ] Yes [ ] No Is property insurance included? [ ] Yes [ ] No Utilities (electricity, heating fuel, $____ $____ water, sewer, and Telephone) Home maintenance (repairs and upkeep) $____ $____ Food $____ $____ Clothing $____ $____ Laundry and dry-cleaning $____ $____ Medical and dental expenses $____ $____ Transportation (not including motor $____ $____ vehicle payments) Recreation, entertainment, $____ $____ newspapers, magazines, etc. Insurance (not deducted from wages or $____ $____ included in Mortgage payments) Homeowner's or renter's $____ $____ Life $____ $____ Health $____ $____ Motor Vehicle $____ $____ Other: ______________________________ $____ $____ Taxes (not deducted from wages or $____ $____ included in Mortgage payments) (specify): _________________________ Installment payments $____ $____ Motor Vehicle $____ $____ Credit card (name): ________________ $____ $____ Department store (name): ___________ $____ $____ Other: _____________________________ $____ $____ Alimony, maintenance, and support $____ $____ paid to others Regular expenses for operation of $____ $____ business, profession, or farm (attach detailed statement) Other (specify): ____________________ $____ $____ Total monthly expenses: $____ $____ 9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? [ ] Yes [ ] No If yes, describe on an attached sheet. 10. Have you paid — or will you be paying — an attorney any money for services in connection with this case, including the completion of this form? [ ]Yes [ ] No If yes, how much? $__________ If yes, state the attorney's name, address, and telephone number: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 11. Have you paid — or will you be paying — anyone other than an attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion of this form? Yes No If yes, how much? $__________ If yes, state the person's name, address, and telephone number: _________________________________________________________________ _________________________________________________________________ 12. Provide any other information that will help explain why you cannot pay the docket fees for your appeal. 13. State the address of your legal residence. _________________________________________________________________ _________________________________________________________________ Your daytime phone number: ____________________ Your age: ________ Your years of schooling: ________ Signed under penalty of perjury: ____________________________ Date: ____________________________MUST BE COMPLETED BY PLAINTIFF Authorization for Release of Institutional Account Information and Payment of the Appeal Filing Fee
28 U.S.C. Section 1915 I, _____________________________________, ____________________________________ (Name of Plaintiff) (Prisoner Number) authorize the Clerk of Court to obtain, from the agency having custody of my person, information about my institutional account, including balances, deposits and withdrawals. The Clerk of Court may obtain my account information from the past six months and in the future, until the appeal filing fee is paid. I also authorize the agency having custody of my person to withdraw funds from my account and forward payments to the Clerk of Court, in accord with . _________________________________ (Signature of Plaintiff) _________________________________ (Date) IT IS PLAINTIFF'S RESPONSIBILITY TO HAVE THE APPROPRIATE PRISON OFFICIAL COMPLETE AND CERTIFY THE CERTIFICATE BELOW CERTIFICATE TO BE COMPLETED BY AUTHORIZED OFFICER (Prisoner Accounts Only) I certify that the applicant named herein has the sum of $_____________________ on account to his credit at the ___________________________________ institution where he is confined. I further certify that the applicant likewise has the following securities to his credit according to the records of said institution:_______________________________________________________ balance deposit
I further certify that during the last six (6) months the plaintiff's average monthly was $________. I further certify that during the last six (6) months the plaintiff's average monthly was $________. _______________________ ______________________________ TELEPHONE NUMBER AUTHORIZED OFFICER OF INSTITUTION OF OFFICER FOR VERIFICATION ______________________________ _______________________ PRINT NAME OF AUTHORIZED OFFICER DATE RETURN COMPLETED FORM TO: U. S. DISTRICT CLERK P.O. BOX 23552 JACKSON, MS 39225