Simpson v. USA et al

Filing 4

MEMORANDUM AND ORDER granting 2 MOTION for Leave to Proceed in forma pauperis filed by David L. Simpson.Signed by Judge J. Phil Gilbert on 6/23/2017. (Attachments: # 1 IFP Consent Form)(jaj)

UNITED STATES DISTRICT COURT
for the
Southern District of Illinois

CONSENT FORM -- IN FORMA PAUPERIS PROCEEDINGS
CASE NAME: David L. Simpson, 08701-026

CASE NUMBER: 17-563-JPG

Instructions to Incarcerated Plaintiff/Petitioner:
By completing this form, which incorporates provisions of the Prison Litigation Reform Act of 1995, 28 U.S.C. § 1915
(as amended), you are authorizing the Institution where you are confined (“the Institution”) to pay to the Clerk of the
United States District Court, Southern District of Illinois, the [$350.00 or $505.00?] [district court/appellate court] filing
fee (“filing fee”) from your prison account for this action.
1.
So that I may file this action, I,_________________________________(print name),
ID # _________________, authorize officials at the Institution to withdraw a first payment from my account that will be
applied toward the filing fee. Institution officials are authorized to pay to the Clerk this first payment from funds in my
account as soon as they become available. This first payment will be the greater of the following amounts:
(a)
20% of the average monthly deposits to my account for the 6-month period immediately preceding the
date I filed this action (as noted above); or
(b)
20% of the average monthly balance in my account for that 6-month period.
Institution officials are authorized to pay to the Clerk this first payment from funds in my account as soon
as they become available.
2.
I further authorize Institution officials to make additional monthly payments from my account until the balance of
the filing fee is paid. These additional monthly payments will be equal to 20% of all of the preceding month’s deposits to
my account. Institution officials shall make monthly payments for me by deducting from my account all monies on
deposit in excess of $10.00 until the full filing fee is paid.
3.
If, before I have paid the filing fee, the Court disposes of my case, I authorize the Institution to continue making
monthly payments to the Clerk of this Court until the full amount of the filing fee is paid. This means that regardless of
the Court’s disposition of my case, I MUST STILL PAY THE ENTIRE FILING FEE.
4.
Additionally, the Court may enter a JUDGMENT AGAINST ME FOR PAYMENT OF COSTS at the conclusion
of this matter to include any unpaid portion of the required filing fee. If the Court does so, I also authorize prison officials
or custodial agents to pay from my prison account to the Clerk of this Court THE FULL AMOUNT OF THE COSTS
ORDERED, using the installment payment plan explained above.
5.
If I am transferred to another prison or custodial agency, I hereby consent that this authorization will continue to
apply, and the new prison or custodial agency shall assume the duties of collecting and forwarding any remaining monthly
payments to the Clerk of this Court.
Signature of Plaintiff:__________________________________________

Date:__________________________

When this form is complete and signed, return it to the following address:
Clerk of the Court
United States District Court
Southern District of Illinois
750 Missouri Avenue
P. O. Box 249
East St. Louis, Illinois 62202
PS-13
Rev. 4/12