Williams v. United States Medical Center for Federal Prisoners
MEMORANDUM AND ORDER: IT IS HEREBY ORDERED that the Clerk is directed to send plaintiff (1) a copy of the Courts Order dated June 1, 2017, (2) a prisoner civil rights complaint form, and (3) a copy of the motion to proceed in forma pauperis form f or prisoners. IT IS FURTHER ORDERED that plaintiff must comply with the instructions set forth in the June 1, 2017, Order no later than twenty-one (21) days from the date of this Order. IT IS FURTHER ORDERED that if plaintiff fails to comply with these Orders, the Court will dismiss this action without further proceedings. Signed by Magistrate Judge Noelle C. Collins on July 7, 2017. (Attachments: # 1 Prisoner Civil Rights Complaint, # 2 Motion to Proceed IFP)(BRP)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
MOTION TO PROCEED IN FORMA PAUPERIS
AND AFFIDAVIT IN SUPPORT -- PRISONER CASES
declare (1) that I am the
in this case; (2) that because
of my poverty, I am unable to pay the $350.00 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, I answer the following
1. Have you ever before brought an action or appeal in a federal
court while you were incarcerated or detained?
If so, how many times?
Were any of the actions or appeals dismissed because they were
frivolous, malicious, or failed to state a claim upon which relief
may be granted?
If so, how many of them?
2. Place of confinement of plaintiff or petitioner:
3. Crime(s) for which you have been convicted, date and sentence on
4. Are you presently employed?
a. If the answer is "yes," state the amount of your salary or
wages per month, and give the name and address of your
b. If the answer is "no," state the date of last employment
and the amount of the salary and wages per month which you
5. Have you received, within the past twelve (12) months, money
from any of the following sources?
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," describe the source
and amount of money received from each during the past twelve
6. Do you own any cash, or do you have money in a checking or
savings account? Include any funds in prison accounts during
the last six (6) months.
If the answer is "yes," state the total amount of cash owned,
and the average monthly balance in all checking, savings or
prison account during the last six (6) months.
7. Do you own real estate, stocks, bonds, notes, automobiles, or
other valuable property (excluding ordinary household
furnishings and clothing)?
If the answer is "yes," describe the property and state its
8. 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
(Signature of plaintiff)
NOTE: THIS AFFIDAVIT MUST BE ACCOMPANIED BY A CERTIFIED
COPY OF YOUR PRISON ACCOUNT STATEMENT SHOWING THE AMOUNT
OF MONEY ON DEPOSIT DURING THE LAST SIX (6) MONTHS. A
"CERTIFIED COPY" OF YOUR ACCOUNT STATEMENT IS ONE THAT HAS
BEEN CERTIFIED BY AN AUTHORIZED PRISON OFFICER THAT IT IS
A TRUE AND CORRECT COPY. FAILURE TO SUBMIT A CERTIFIED
ACCOUNT STATEMENT WILL RESULT IN THE RETURN OF YOUR
COMPLAINT OR PETITION.
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?