Hayes v. Federal Reserve Bank of St. Louis

Filing 22

MEMORANDUM AND ORDER: IT IS FURTHER ORDERED that the Clerk shall mail to plaintiff a form "Motion to Proceed In Forma Pauperis and CJA-23 Financial Affidavit." IT IS FURTHER 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 completed form "Motion to Proceed In Forma Pauperis and Financial Affidavit." IT IS FURTHER ORDERED that if plaintiff fails to comply with this Order, the Court m ay dismiss this action without prejudice. IT IS FINALLY ORDERED that Defendant's Motion to Strike Plaintiffs Sur-Reply (ECF No. 20) and Plaintiffs Counter Motion to Strike Defendant's Sur-Reply (ECF No. 21) are DENIED. Signed by District Judge Ronnie L. White on October 8, 2015. (Attachments: # 1 CJA 23 Form)(BRP)

Reset
O CJA 23

FINANCIAL AFFIDAVIT

Rev. 5/98

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

MAGISTRATE

DISTRICT

APP EALS COURT or

OTHER PANEL (Specify below)
LOCA TION NU M BER

*

FOR
V.S.
AT

1

De fend ant - J uve nile
Ap p ellant
Probation Violator
Parole Violator

Felony

6

Hab eas P etit ioner

M isdemeanor

7
8

225 5 P etit ioner
M aterial Witness

9

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

2
3
4
5

*

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

DOCK ET NU M BERS
M agistrate

Ot her

*

District Court
Co urt of A p p eals

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?
RECEIVED

OTHER
INCOME

ASSETS

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

9

M ARITAL STATUS

DEPENDENTS

9
OBLIGATIONS &
DEBTS

9

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

9
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.)

9

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

*

$