Phillips v. Psychiatrist et al

Filing 2

OPINION, MEMORANDUM AND ORDER. IT IS HEREBY ORDERED that, within fourteen (14) days of the date of this Order, plaintiff shall either pay the $405 filing fee, or file a motion for leave to proceed in forma pauperis. IT IS FURTHER ORDERED that the Clerk shall mail to plaintiff a copy of the Courts form Application to Proceed in District Court Without Prepaying Fees or Costs. (Response to Court due by 4/9/2024.) Signed by District Judge Henry Edward Autrey on 3/26/2024. (Attachments: #1 Form)(JEB)

Clear Form
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
_________ DIVISION
______________________________,

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) Civil Case No. _______
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Plaintiff,
v.
______________________________,
Defendant(s).

APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS
(Short Form)
I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings and
that I am entitled to the relief requested.
In support of this application, I answer the following questions under penalty of perjury:
1. If incarcerated. I am being held at:
.
If employed there, or have an account in the institution, I have attached to this document a statement certified by the
appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any
institutional account in my name. I am also submitting a similar statement from any other institution where I was
incarcerated during the last six months.
2. If not incarcerated. If I am employed, my employer’s name and address are:

My gross pay or wages are: $
(specify pay period)

, and my take-home pay or wages are: $

per

.

3. Other Income. In the past 12 months, I have received income from the following sources (check all that apply):
(a)
(b)
(c)
(d)
(e)
(f)

Business, profession, or other self-employment
Rent payments, interest, or dividends
Pension, annuity, or life insurance payments
Disability or worker’s compensation payments
Gifts or inheritances
Any other sources

___ Yes
___ Yes
___ Yes
___ Yes
___ Yes
___ Yes

___ No
___ No
___ No
___ No
___ No
___ No

If you answered “Yes” to any question above, describe below or on separate pages each source of money and
state the amount that you received and what you expect to receive in the future.

4. Amount of money that I have in cash or in a checking or savings account: $

.

5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or
thing of value that I own, including any item of value held in someone else’s name (describe the property and its approximate
value):

6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide
the amount of the monthly expense):

7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship
with each person, and how much I contribute to their support:

8. Any debts or financial obligations (describe the amounts owed and to whom they are payable):

Declaration: I declare under penalty of perjury that the above information is true and understand that a false
statement may result in a dismissal of my claims.

______________________________________
Applicant’s Signature
______________________________________
Printed Name
______________________________________
Date