Phillips v. Blanks et al

Filing 4

MEMORANDUM AND ORDER IT IS HEREBY ORDERED that plaintiff shall have until May 18, 2015 to either (1) pay the full statutory filing fee, or (2) submit a fully-completed CJA Form 23 financial affidavit. IT IS FURTHER ORDERED that, upon plaintiff' ;s submission of a timely and fully- completed CJA Form 23 financial affidavit, 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 financial affidavit by May 18, 2015, this case will be dismissed, without prejudice and without further notice. Signed by District Judge Charles A. Shaw on 4/17/15. (Attachments: # 1 CJA 23)(KXS)

FINANCIAL AFFIDAVIT

CJA 23

IN SUPPORT OF REQUEST FOR ATT ORNEY, EXPERT OR OTHER COURT SERVICES WITHOUT PAYMENT OF FEE

Rev. 5/98

IN UN IT ED S TA TES
IN THE CASE

MAGISTRATE

DISTRICT

APP EALS COURT or

OTHER PANEL (Specify below)
LOCA TION NU M BER

FOR
V.S.
AT

PER SON REP RESENT ED ( Show y our full name)

1

Probation Violator
Parole Violator

District Court

Felony

6

Hab eas P etit ioner

Co urt of A p p eals

M isdemeanor

7
8

225 5 P etit ioner
M aterial Witness

9

)

De fend ant - J uve nile
Ap p ellant

4
5
CH A RG E/ O F F EN SE (des cr ib e i f ap p lica ble & c hec k box

De fend ant —A dult

2
3

DOCK ET NU M BERS
M agistrate

Ot her

ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY
Are yo u no w empl o ye d?

Ye s

No

Am Self-Employed

Name and address of employer:
EMPLO YMENT

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? $

No

Ye s

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
No
Yes
the form of rent payments, interest, dividends, retirement or annuity payments, or other sources?
ASSETS

RECEIVED

OTHER
INCOME

IF YES, GIVE THE AMOUNT
RECEIVED & IDENTIFY
THE SOURCES

CAS H

S OURCES

$

Have yo u an y cas h on han d or money in sav ings or checking a ccou nts ?

Ye s

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 )?

Ye s

No
VALUE

PROPERTY

M ARITAL STATUS

DEPENDENTS

OBLIGATIONS &
DEBTS

DESCRIPTION

IF YES, GIVE THE VALUE AND $
DESCRIBE IT

DEB TS &
MONTHLY
B ILLS

SINGLE
M ARRIED
WIDO WED
SEPARATED OR
DIVORCED
APARTMENT
OR HO M E:

Total
No. of
Dependents

List p ersons y ou act ually sup p ort and y our relationship to them

Creditors

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,
ET C.)

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

$