CIVIL ACTION NO. 1:10-cv-494-HSO-JMR.
November 16, 2010
JOHN ROPER SR., Magistrate Judge
On October 15, 2010, an order [2] was entered directing Petitioner to file an application to proceed in forma pauperis or to pay the $5.00 filing fee, on or before November 5, 2010. On November 9, 2010, Petitioner filed a response [3] and attachment [4]. Petitioner's response [3] stated that he feared that he would be unable to meet the Court's deadline for filing his application to proceed in forma pauperis along with the certificate to be completed by the authorized officer in charge of inmate accounts, therefore, he attached a certificate completed July 16, 2010, which he submitted in a previous § 1983 case. Further, Petitioner's attachment [4] provided this Court with a completed application to proceed in forma pauperis in the state courts of Mississippi. As such, the Petitioner will be provided an extension of time to provide this Court with a current inmate account certificate as well as a completed application to proceed in forma pauperis in this Court. Accordingly, it is,
ORDERED:
1. That Petitioner is granted until and including December 7, 2010, to comply with the Court's order [2] of October 15, 2010, by filing the attached application to proceed in forma pauperis in this Court including a current completed certificate portion OR pay the required filing fee of $5.00.
2. The Clerk shall mail the attached application to proceed in forma pauperis to the Petitioner at his last known address.
3. That failure of the Petitioner to advise this Court of a change of address or failure to timely comply with any order of this Court will be deemed as a purposeful delay and contumacious act by the Petitioner and may result in this cause being dismissed without further notice to the Petitioner.
4. That the Petitioner is required to file his original response to this order to show cause with the Clerk, 2012 15th Street, Suite 403, Gulfport, Mississippi 39501. Failure to properly file a response may result in this civil action being dismissed.
THIS, the 16th day of November, 2010.
MOTION TO PROCEED IN FORMA PAUPERIS
I, _______________________________________________________ (name), ______________ (prisoner number), declare that I am the petitioner 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 said proceedings or give security therefor; that I believe I am entitled to the relief. Signed: ____________________________ Date: __________________________________________ __________________________________________________________________________________________________ AFFIDAVIT IN SUPPORT OF MOTION
In support of this motion, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated? ___ Yes ___ No If "yes" state the place of your incarceration ______________________________________________ 2. Are you presently employed (at the institution or otherwise)? ___ Yes ___ No 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 the last employment and the amount of the salary and wages per month which you received. __________________________________________________ __________________________________________________________________________________________ 3. Have you received within the past twelve months any money from any of the following sources? a. Business, profession or form of self-employment? ___ Yes ___ No b. Rent payments, interest or dividends? ___ Yes ___ No c. Pensions, annuities or life insurance payments? ___ Yes ___ No d. Gifts or 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 twelve months. ____________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 4. Do you own cash, or do you have money in a checking or savings account? ___ Yes ___ No (Include any funds in prison accounts.) If the answer is "yes," state the total value of the items owned. ___________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 5. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? ___ Yes ___ No If the answer is "yes," describe the property and state its approximate value. ______________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 6. List the persons who are dependent upon you for support, state your relationship to those persons, and indicate how much you contribute toward their support. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ I declare (or certify, verify or state) under penalty of perjury that the foregoing is true and correct. Executed on ________________________ _____________________________________________________ Date Signature of Petitioner Certificate
I hereby certify that the petitioner herein has the sum of $____________ on account to his credit at the _____________________________ institution where he is confined. I further certify that petitioner likewise has the following securities to his credit according to the records of said ___________________________________________ institution: ______________________________________________. _________________________________ ________________________________________________ Date Authorized Officer of Institution