Parrish v. National Geospatial Intelligence Agency
MEMORANDUM AND ORDER: IT IS HEREBY ORDERED that plaintiff shall have thirty (30) days from the date of this Order to pay the statutory filing fee of $400, or to submit a fully-completed CJA Form 23 (financial affidavit). IT IS FURTHER ORDERED t hat, upon plaintiffs submission of a fully-completed CJA Form 23, the Clerk shall cause this case to be resubmitted for review under 28 U.S.C. § 1915. IT IS FURTHER ORDERED that if plaintiff fails to pay the filing fee or to submit a fully-completed CJA Form 23 within thirty days, this case shall be dismissed, without prejudice. (Response to Court due by 4/12/2015.) Signed by District Judge Ronnie L. White on March 13, 2015. (Attachments: # 1 CJA 23 Form)(BRP)
O CJA 23
IN SUPPORT OF REQUEST FOR ATT ORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE
IN UN IT ED S TA TES
IN THE CASE
APP EALS COURT or
OTHER PANEL (Specify below)
LOCA TION NU M BER
De fend ant - J uve nile
Ap p ellant
Hab eas P etit ioner
225 5 P etit ioner
M aterial Witness
CH A RG E/ O F F EN SE (des cr ib e i f ap p li ca ble & c hec k box ÿ )
De fend ant —A dult
PER SON REP RESENT ED ( Show y our full name)
DOCK ET NU M BERS
Co urt of A p p eals
ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are yo u no w empl o ye d?
Name and address of employer:
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? $
If m arr ie d is yo ur Spo us e e mpl o ye d?
IF YES, how much does your
Spouse earn per month? $
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
the form of rent payments, interest, dividends, retirement or annuity payments, or other sources?
IF YES, GIVE THE AMOUNT
RECEIVED & IDENTIFY
Have yo u an y cas h on han d or money in sav ings or checking a ccou nts ?
N o IF Y ES , state total amoun t $
Do you own any real estate, stocks, bonds , notes, automobiles, or other valuable property (excluding ordinary hous ehold furnish ings and
clo th ing )?
M ARITAL STATUS
IF YES, GIVE THE VALUE AND $
DEB TS &
OR HO M E:
List p ersons y ou act ually sup p ort and y our relationship to them
Tot al Debt
M onthly Paymt.
IN CLU D IN G BA N K S,
LO A N CO MP A N IE S,
(L IST AL L CR ED IT O RS,
CH A RG E A CCO U N TS,
I certify under penalty of perjury that the foregoing is true and correct. Executed on (date)
SIGNATURE OF DEFENDANT
(OR PERSON REPRESENTED)
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