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)

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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) $

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