King v. Sachse

Filing 3

MEMORANDUM AND ORDER : IT IS HEREBY ORDERED that the Clerk is directed to send petitioner a motion for leave to proceed in forma pauperis form. IT IS FURTHER ORDERED that, no later than twenty-eight (28) days from this Memorandum and Order, petit ioner must either pay the $5 filing fee or file a motion for leave to proceed in forma pauperis. IT IS FURTHER ORDERED that if petitioner fails to comply with this Order, the Court may dismiss this action without further proceedings. Signed by District Judge Audrey G. Fleissig on 04/07/2017. (Attachments: # 1 Attachment)(KCB)

Reset

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
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Petitioner
VS.

Respondent

Case No.

MOTION TO PROCEED IN FORMA PAUPERIS
AND AFFIDAVIT IN SUPPORT
HABEAS CASES
I
declare (1) that I am the petitioner in this case; (2) that because
of my poverty I am unable to pay the filing fee and (3) that I
believe I am entitled to relief. The nature of my action and the
issues are briefly stated as follows.

In further support of this application,
questions

I answer the following

1. Place of confinement of petitioner:

2. Crime(s) for which you have been convicted, date and sentence on
each:

3. Are you presently employed?
a.

Yes

No

If the answer is ''yes
state the amount of your salary or
wages per month and give the name and address of your
employer.

b.

If the answer is ''no
state the date of last employment
and the amount of the salary and wages per month which you
received.

4. Have you received within the past twelve (12) months, money
from any of the following sources?
Yes No
Business profession or form of self-employment?
Rent payments interest or dividends?
Pensions annuities or life insurance payments?
Gifts or inheritances?
Any other sources?

,

If the answer to any of the above is ''yes 11 describe the source
and amount of money received from each during the past twelve
(12) months.

5. Do you own any cash or do you have money in a checking or
savings account? Include any funds in your prison account.
No
Yes
If the answer is ''yes
state the total amount of cash owned,
and the balance in all checking savings or prison accounts.

6. Do you own real estate stocks bonds notes automobiles,
other valuable property (excluding ordinary household
furnishings and clothing)'~'
No
Yes
If the answer is ''yes
approximate value.

describe the property and state its

2

or

I

7. List the persons who are dependent upon you for support state
your relationship to those persons and indicate how much you
contribute toward their support

I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION
IS TRUE AND CORRECT. I UNDERSTAND THAT PROVIDING FALSE INFORMATION
MAY SUBJECT ME TO CRIMINAL PROSECUTION IMPOSITION OF A FINE OR
OTHER SANCTION THAT MAY ADVERSELY AFFECT MY ABILITY TO PURSUE THIS
CASE OR OTHER CASES. I HAVE REVIEWED MY ANSWERS TO INSURE THEIR
ACCURACY
Executed (signed) this
day of
.
F 20

(Signature of petitioner)

Certificate
I certify that the applicant named herein has the sum of
on account to his credit at the
is
institution where he
confined.
I further certify that the applicant likewise has the
following securities to his credit according to the records of said
institution:
$

Authorized Officer of Institution

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