Bodway v. Mallard, et al.,

Filing 7

MEMORANDUM AND ORDER...IT IS HEREBY ORDERED that, on or before February 5, 2016, plaintiff shall file an amended complaint, in accordance with the Courts November 9, 2015 Memorandum and Order. IT IS FURTHER ORDERED that, on or before February 5, 20 16, plaintiff shall complete and submit Form CJA-23 Financial Affidavit. IT IS FURTHER ORDERED that plaintiffs failure to comply with the instant Memorandum and Order will result in the dismissal of this action, without prejudice and without further notice. IT IS FURTHER ORDERED that the Clerk of Court shall provide plaintiff with a copy of the Courts November 9, 2015 Memorandum and Order [Doc. # 4 ], as well as Form CJA-23 Financial Affidavit. (Response to Court due by 2/5/2016.) Signed by District Judge Audrey G. Fleissig on 1/21/2016. (Attachments: # 1 Form)(NEB)

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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 UNITED S TATES IN THE CASE MAGISTRATE DISTRICT APP EALS COURT or OTHER PANEL (Specify below) LOCA TION NU M BER * FOR V.S. AT 1 Defendant - Juvenile Ap p ellant 4 5 Probation Violator Parole Violator Felony 6 Habeas Petit ioner 7 8 2255 Petit ioner M aterial Witness 9 CHARGE/OFFEN SE (describe if ap p licable & check box ÿ ) Defendant —A dult 2 3 M isdemeanor * PERSON REPRESENT ED (Show your full name) Ot her DOCK ET NU M BERS M agistrate * District Court Court of A p p eals ANSWERS TO QUESTIONS REGARDING ABILITY TO PAY Are you now employed? Yes 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 Yes If married is your Spouse employed? 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 ? Yes N o IF YES , 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 )? 9 Yes No VALUE PROPERTY 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) *

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