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)

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UNITED STATES DISTRICT COURT For the Southern District of Illinois ) ) ) ) ) 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. 2 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) 3 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 4

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