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)

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)

*