White v. Lewandowski et al

Filing 5

ORDER directing the Clerk to serve this Order on Plaintiffs custodian and to include a Prisoner Trust Fund Account Statement with that service copy. The custodian is to complete and return the form to the Plaintiff. Plaintiff must then return the Tru st Fund Account Statement, along with the Consent to Collection of Fees form, to the Court by no later than May 26, 2017. The Court directs the Clerk to enclose a copy of the Consent to Collection of Fees form with Plaintiffs service copy of this Order. Compliance due by 5/26/2017. Signed by Magistrate Judge Brian K. Epps on 05/08/2017. (thb) (Additional attachment(s) added on 5/8/2017: # 1 Prisoner Trust Fund Account Statement and Consent to Collection of Fees from Trust Account) (thb).

Augusta, Brunswick, or Savannah? Augusta

RESET FORM

This form is to be used ONLY in Judge Barfield cases.

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF GEORGIA
Scott L. Poff
Clerk

[phone]

OFFICE OF THE CLERK
P.O. Box 1130
Augusta, Georgia 30903

RODERICK MAURICE WHITE,

Plaintiff,
v.
S. LEWANDOWSKI, Correctional Officer,
Augusta State Medical Prison, et al.,

CASE NUMBER:

CV1:17-42

Defendant.

PRISONER TRUST FUND ACCOUNT STATEMENT
Under the Prison Litigation Reform Act, a prisoner seeking to bring a civil action without prepayment of
fees must obtain from the appropriate prison official a certified copy of the prisoner's trust account statement
for the six-month period immediately preceding the submission of the complaint to the Court. The plaintiff
in this case has been instructed by the Court to furnish this form to the trust officer of each institution where
he has been confined for the last six months.
Please complete this form, attach the supporting ledger sheets, and return these documents to the prisoner
for mailing to this Court.
DATE COMPLAINT RECEIVED:

04/11/2017
__________________________________

AVERAGE MONTHLY DEPOSITS during
the six months prior to receipt of the complaint:

__________________________________

AVERAGE MONTHLY BALANCE during
the six months prior to receipt of the complaint:

__________________________________

I certify that the above information accurately states the deposits and balances in the plaintiff's trust
account for the period shown and that the attached ledger sheets are true copies of the account records
maintained by this institution.

__________________________________
Signature of Authorized Officer of Institution

__________________________________
Print or type name

__________________________________
Date

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF GEORGIA
Scott L. Poff
Clerk

OFFICE OF THE CLERK
P.O. Box 1130
Augusta, Georgia 30903

[phone]

RODERICK MAURICE WHITE,

Plaintiff,
v.
S. LEWANDOWSKI, Correctional Officer,
Augusta State Medical Prison, et al.,

CASE NUMBER:

CV1:17-42

Defendant.

CONSENT TO COLLECTION OF FEES FROM TRUST ACCOUNT
As a condition to proceeding with this lawsuit, I hereby consent for the appropriate prison officials to
withhold from my prison account and pay to the Court an initial partial filing fee equal to 20 percent of the
greater of
(a) the average monthly deposits to my account, or
(b) the average monthly balance in my account
for the six-month period immediately preceding the filing of my complaint. I understand that I may not
withdraw any monies from my account until this initial payment has been paid.
After the payment of any initial partial filing fee, I further consent for the appropriate prison officials to
collect from my account on a continuing basis each month an amount equal to 20 percent of all deposits
credited to my account, Each time the set aside amount reaches $10.00, the trust officer shall forward the
payment to:
Clerk's Office, United States District Court
P.O. Box 1130
Augusta, Georgia 30903
until such time as the $350.00 filing fee is paid in full.
until such time as the $350.00 filing fee is paid in full. In the event that I file a Notice of Appeal, I also give
my consent for the appropriate prison officials to similarly collect from my account the applicable appellate
By executing
court filing fee. this document, I also authorize collection on a continuing basis of any additional costs
which may be imposed by the Court.
By executing this document, I also authorize collection on a continuing basis of any additional costs
which may be imposed by the Court.
Date: ________________
Plaintiff's Signature: ____________________________

Date: ______________________

Plaintiff's Prison No: ____________________________
Plaintiff's Signature: ___________________________

Plaintiff's Prison No: ___________________________