Opinion
ORDER
CAROLYN K. DELANEY, Magistrate Judge.
Plaintiff's motion to proceed in forma pauperis was referred to the undersigned by minute order dated November 10, 2015. Plaintiff has not paid the fee ordinarily required to file an action in this court, and has filed an incomplete application to proceed without prepayment of fees. See 28 U.S.C. §§ 1914(a), 1915(a). Plaintiff states she is currently employed but does not state the amount of her take-home salary or wages and pay period and does not provide the name and address of her last employer. Plaintiff also does not state the value of her car and does not indicate the amount plaintiff contributes to the support of her family. Plaintiff will be provided the opportunity to submit either the appropriate affidavit in support of a request to proceed in forma pauperis or the appropriate filing fee.
In accordance with the above, IT IS HEREBY ORDERED that:
1. Plaintiff shall submit, within fourteen days from the date of this order, either a completed application and affidavit in support of his request to proceed in forma pauperis on the form provided by the Clerk of Court, or the appropriate filing fee; plaintiff's failure to comply with this order will result in a recommendation that this action be dismissed; and
2. The Clerk of the Court is directed to send plaintiff a new Application to Proceed In Forma Pauperis.
Plaintiff DefendantAPPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Short Form)
I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief requested.
In support of this application, I answer the following questions under penalty of perjury:
1. If incarcerated. I am being held at:.
If employed there, or have an account in the institution, I have attached to this document a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any institutional account in my name. I am also submitting a similar statement from any other institution where I was incarcerated during the last six months.
2. If not incarcerated. If I am employed, my employer's name and address are:
My gross pay or wages are: $ ____________, and my take-home pay or wages are: $ _________________ per (specify pay period) _______________________________.
3. Other Income. In the past 12 months, I have received income from the following sources (check all that apply):
(a) Business, profession, or other self-employment [] Yes [] No
(b) Rent payments, interest, or dividends [] Yes [] No
(c) Pension, annuity, or life insurance payments [] Yes [] No
(d) Disability, or worker's compensation payments [] Yes [] No
(e) Gifts, or inheritances [] Yes [] No
(f) Any other sources [] Yes [] No
If you answered "Yes" to any question above, describe below or on separate pages each source of money and state the amount that you received and what you expect to receive in the future.
4. Amount of money that I have in cash or in a checking or savings account: $ __________________.
5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or thing of value that I own, including any item of value held in someone else's name (describe the property and its approximate value):
6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide the amount of the monthly expense):
7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship with each person, and how much I contribute to their support:
8. Any debts or financial obligations (describe the amounts owed and to whom they are payable):
Declaration: I declare under penalty of perjury that the above information is true and understand that a false statement may result in a dismissal of my claims.
Applicant's signature Printed name