Andres Medina v. Debbie Asuncion et al

Filing 6

ORDER TO SHOW CAUSE AS TO WHY THIS ACTION SHOULD NOT BE DISMISSED by Magistrate Judge Alexander F. MacKinnon. Accordingly, Plaintiff is hereby ORDERED TO SHOW CAUSE as to why this action should not be dismissed. To avoid dismissal, Plaintiff must, within fourteen (14) days: (1) submit an exact copy of his complaint to designated CSPLAC staff for scanning and emailing to the Court, OR file a response to this Order explaining why he should be exempt from General Order No. 18-02 and allowed to file by United States mail; AND (2) either pay the full filing fee of $400 (a $350 filing fee plus a $50 administrative fee) or submit a completed Request to Proceed Without Prepayment of Filing Fees with Declaration in Support form (CV-60P), along with a CERTIFIED copy of his trust account statement for the past six months (or institutional equivalent) and a disbursement notification. (See document for further details.) (Attachments: # 1 CV-60P) (sbou)

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UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA CASE NUMBER v. PLAINTIFF/PETITIONER, REQUEST TO PROCEED IN FORMA PAUPERIS WITH DECLARATION IN SUPPORT DEFENDANT(S). , declare under penalty of perjury, that the foregoing is true and I, correct; that I am the petitioner/plaintiff in the above entitled case; that in support of my motion to proceed without being required to prepay fees, costs or give security therefore, I state that because of my poverty I am unable to pay the costs of said proceedings or to give security therefore and that I am entitled to redress. I further declare under penalty of perjury that the responses which I have made to the questions and instructions below are true, correct and complete. 1. Are you presently employed? GYes GNo 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? GYes GNo b. Rent payments, interest or dividends? GYes GNo c. Pensions, annuities or life insurance payments? GYes GNo d. Gifts or inheritances? GYes GNo e. Any other income (other than listed above)? GYes GNo f. Loans? GYes GNo If the answer to any of the above is yes, describe such source of money and state the amount received from each source during the past twelve (12) months: CV-60 (04/06) REQUEST TO PROCEED IN FORMA PAUPERIS WITH DECLARATION IN SUPPORT Page 1 of 2 3. Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prison accounts, if applicable.) GYes GNo If the answer is yes, identify each account and separately state the amount of money held in each account for each of the six (6) months prior to the date of this declaration. 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? GYes GNo If the answer is yes, describe the property and state its approximate value: 5. In what year did you last file an Income Tax return? Approximately how much income did your last tax return reflect? 6. List the persons who are dependent upon your for support, state your relationship to those persons, and indicate how much you contribute toward their support: I understand that a false statement or answer to any question in this declaration will subject me to penalties for perjury. I further understand that perjury is punishable by a term of imprisonment of up to five (5) years and/or a fine of $250,000 (18 U.S.C. Sections 1621, 3571). State I, foregoing is true and correct. Date CV-60 (04/06) County (or City) , declare under penalty of perjury that the Plaintiff/Petitioner (Signature) REQUEST TO PROCEED IN FORMA PAUPERIS WITH DECLARATION IN SUPPORT Page 2 of 2

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