Williams v. United States Medical Center for Federal Prisoners

Filing 5

MEMORANDUM AND ORDER: IT IS HEREBY ORDERED that the Clerk is directed to mail to plaintiff a copy of the Courts prisoner civil rights complaint form. IT IS FURTHER ORDERED that the Clerk is directed to mail to plaintiff a copy of the motion to pro ceed in forma pauperis form for prisoners. IT IS FURTHER ORDERED that plaintiff must file an amended complaint on the Courts form within thirty (30) days of the date of this Order. IT IS FURTHER ORDERED that plaintiff must either pay the $400 f iling fee or submit a motion to proceed in forma pauperis within thirty (30) days of the date of this Order. IT IS FURTHER ORDERED that if plaintiff files a motion to proceed in forma pauperis, he must also file a certified copy of his prison acco unt statement for the six-month period preceding the filing of the complaint. IT IS FURTHER ORDERED that if plaintiff fails to comply with this Order, the Court will dismiss this action without prejudice. If the case is dismissed for non-complianc e with this Order, the dismissal will not count as a "strike" under 28 U.S.C. § 1915(g). Signed by Magistrate Judge Noelle C. Collins on June 1, 2017. (Attachments: # 1 Prisoner Civil Rights Complaint, # 2 Motion to Proceed to IFP)(BRP)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
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Plaintiff,
vs.

Defendant(s).

Case No.

MOTION TO PROCEED IN FORMA PAUPERIS
AND AFFIDAVIT IN SUPPORT -- PRISONER CASES
I,
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
questions:
1. Have you ever before brought an action or appeal in a federal
court while you were incarcerated or detained?
Yes

No

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?
Yes

No

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
each:

4. Are you presently employed?

Yes

No

a. 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.

5. 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," describe the source
and amount of money received from each during the past twelve
(12) months.

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.
Yes
No
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.

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7. Do you own real estate, stocks, bonds, notes, automobiles, or
other valuable property (excluding ordinary household
furnishings and clothing)?
Yes
No
If the answer is "yes," describe the property and state its
approximate value.

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

day of

, 20

.

(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.

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