Hamilton v. Burke

Filing 3

MEMORANDUM AND ORDER re: 2 ORDERED that petitioner's pro se motion to proceed in forma pauperis [Doc. 2] is DENIED without prejudice. FURTHER ORDERED that the Clerk shall mail to petitioner a copy of the Court's Motion to Proceed In Forma Pauperis and Financial Affidavit forms. FURTHER ORDERED that petitioner shall, within twenty-one (21) days of the date of this Order, either (1) pay the $350 filing fee or (2) submit a complete Motion to Proceed In Forma Pauperis and Financial Affidavit, utilizing the Court provided forms. FURTHER ORDERED that if petitioner fails to comply with this Order, the Court will dismiss this action for failure to prosecute.( Response to Court due by 11/27/2012.). Signed by District Judge Jean C. Hamilton on 11/6/12. (Attachments: # 1 Motion to Proceed In Forma Pauperis)(CEL)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
,
Plaintiff(s),
v.
,
Defendant(s).

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)
)
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)
)
)

No.

MOTION TO PROCEED IN FORMA PAUPERIS
AND FINANCIAL AFFIDAVIT

I,

, hereby apply for leave to proceed in

this action without prepayment of fees or costs and without giving security therefor. In support
of this application, I declare that the following facts are true:
(1)

I am the plaintiff in this case and I believe I am entitled to relief.

(2)
Because of my poverty I am unable to prepay the costs of this
proceeding or to give security therefor.
(3)
The nature of my action, defense, or appeal is briefly stated as
follows:

I declare under penalty of perjury that the foregoing is true and correct. Executed on
, 20

.

Signature of plaintiff

CJA 23

FINANCIAL AFFIDAVIT

Rev. 5/98

IN SUPPORT OF REQUEST FOR ATTORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE
G MAGISTRATE

IN UNITED STATES

G DISTRICT

G APPEALS COURT or

G OTHER PANEL (Specify below)

IN THE CASE OF

LOCATION NUMBER
FOR



V.S.
AT

1 G Defendant—Adult
2 G Defendant - Juvenile

PERSON REPRESENTED (Show your full name)



DOCKET NUMBERS
Magistrate

3 G Appellant
4 G Probation Violator
CHARGE/OFFENSE (describe if applicable & check box )



5 G Parole Violator
6 G Habeas Petitioner

G Felony
G Misdemeanor

District Court
Court of Appeals

7 G 2255 Petitioner
8 G Material Witness
9 G Other (Specify)

ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are you now employed? G Yes
Name and address of employer:
EMPLOYMENT

G No

G Am Self-Employed

IF YES, how much do you
earn per month? $

IF NO, give month and year of last employment
How much did you earn per month? $

G Yes

If married is your Spouse employed?
IF YES, how much does your
Spouse earn per month? $

G No
If a minor under age 21, what is your Parents or
Guardian’s approximate monthly income? $

Have you received within the past 12 months any income from a business, profession or other form of self-employment, or in the form of
the form of rent payments, interest, dividends, retirement or annuity payments, or other sources?
G Yes
G No
ASSETS

OTHER
INCOME

CASH

RECEIVED

IF YES, GIVE THE AMOUNT
RECEIVED & IDENTIFY
THE SOURCES

SOURCES

$

G

Have you any cash on hand or money in savings or checking accounts?

Yes

G No

IF YES, state total amount $

Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and
clothing)? G Yes
G No
PROPERTY

OBLIGATIONS &
DEBTS



VALUE

DESCRIPTION

IF YES, GIVE THE VALUE AND $
DESCRIBE IT

DEPENDENTS

DEBTS &
MONTHLY
BILLS
(LIST ALL CREDITORS,
INCLUDING BANKS,
LOAN COMPANIES,
CHARGE ACCOUNTS,
ETC.)





Total
No. of
Dependents

MARITAL STATUS
SINGLE



MARRIED
WIDOWED
SEPARATED OR
DIVORCED
APARTMENT
OR HOME:

Creditors

(OR PERSON REPRESENTED)

Total Debt

Monthly Paymt.

$
$

$

$



$

$

I certify under penalty of perjury that the foregoing is true and correct. Executed on (date)
SIGNATURE OF DEFENDANT

List persons you actually support and your relationship to them

$

$