Perkins v. USP Marion et al

Filing 3

NOTICE AND ORDER: The Court has received your Complaint. Your case number is 21-1459-NJR. Within 30 days of the entry of this Order, you are ORDERED to submit the $402.00 filing fee or a motion to proceed without prepayment of the filing fee. If you file a motion to proceed without prepayment of the filing fee, the Court must review your trust fund account statement for the six-month period immediately preceding the filing of this action. Thus, you must have the Trust Fund Officer at your facility complete the attached certification and provide a copy of your trust fund account statement (or institutional equivalent). If you fail to pay the filing fee or submit the motion to proceed without prepayment of the filing fee by the deadline, the case will be dismissed without prejudice for failure to prosecute. FED. R. CIV. P. 41(b); Sperow v. Melvin, 153 F.3d 780, 781 (7th Cir. 1998). All mail should be sent to: Clerk's Office, U.S. District Court, 750 Missouri Avenue, East St. Louis, IL 62201. Finally, you are advised that if your address changes, you must notify the Court within seven days of the change by filing a Notice of Change of Address. Failure to do so could result in the dismissal of your case. Signed by Chief Judge Nancy J. Rosenstengel on 11/19/2021. (jaj)

UNITED STATES DISTRICT COURT
For the Southern District of Illinois
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Plaintiff(s)
v.
Defendant(s)

Case Number:

MOTION AND AFFIDAVIT TO PROCEED
IN DISTRICT COURT
WITHOUT PREPAYING FEES OR COSTS
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 motion, I answer the following questions under penalty of perjury:
1. If incarcerated:
A. I am being held at:
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. NOTE: You must have an
authorized institutional officer complete the last page of this form.

.

B. I declare one of the following:
__ I have NOT had 3 or more civil actions dismissed as being frivolous, malicious, or for
failure to state a claim and/or received 3 or more “strikes” under 28 U.S.C. § 1915(g).
__ I am proceeding under 28 U.S.C. § 1915(g), based on my claim that I am in imminent
danger of serious physical injury.
2 . If not incarcerated:
A. Are you

0

Yes

0

No

employed?

B. If employed, my employer’s name and address are:

C. My gross pay or wages are: $
$

, and my take-home pay or wages are:
per (specify pay period)
.

1

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
selfemployment interest, or dividends
(b) Rent payments,
(c) Pension, annuity, or life insurance payments
(d) Disability or worker’s compensation
payments inheritances
(e) Gifts or
(f) Any other sources

0
0
0
0
0
0

Yes
Yes
Yes
Yes
Yes
Yes

0
0
0
0
0
0

No
No
No
No
No
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.

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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. I
understand that a false statement may result in a dismissal of my claims.

Date:
Movant’s signature

Printed name

AO 240 (Rev. 06/09) Motion to Proceed in District Court Without Prepaying Fees or Costs (Short Form) MODIFIED SDIL (7/2018)

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CERTIFICATION
(TO BE COMPLETED BY AN AUTHORIZED INSTITUTIONAL OFFICER)

Plaintiff/Petitioner:
Institution:
Register Number:

I,

, hereby certify that the
(Name and Title of Authorized Officer - please print)

inmate identified above currently has the sum of $

on account at
.

(Institution where confined)

Signature of Authorized Officer
Dated:

PURSUANT TO 28 U.S.C. § 1915(a)(2), PLEASE
ATTACH A COPY OF THE INMATE’S TRUST
FUND ACCOUNT STATEMENT
FOR THE PAST SIX MONTHS.

Please mail the statement and this completed form to:
Clerk of Court
United States District Court
Southern District of Illinois
750 Missouri Ave.
East St. Louis, IL 62201

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