Fredricks v. Hallett
ORDER DIRECTING PAYMENT OF FEE OR IFP APPLICATION: Petitioner is directed to render payment of the $5.00 filing fee or submit an IFP application to this Court's Pro Se Office within thirty (30) days of the date of this Order. The Clerk of Court is directed to assign this matter to my docket. The Court certifies, pursuant to 28 U.S.C. § 1915(a)(3), that any appeal from this Order would not be taken in good faith, and therefore in forma pauperis status is de nied for the purpose of an appeal. See Coppedge v. United States, 369 U.S. 438, 444-45 (1962). Filing Fee due by 5/27/2021. In Forma Pauperis (IFP) Application due by 5/27/2021. (Signed by Judge Laura Taylor Swain on 4/27/2021) (Attachments: # 1 IFP Application) (keb) Transmission to Docket Assistant Clerk for processing.
U NIT ED S TATES D ISTRICT C OURT
S OUTHERN D ISTRICT OF N EW Y ORK
(Full name(s) of the plaintiff or petitioner applying (each person
must submit a separate application)
(Enter case number and initials of assigned judges, if
available; if filing this with your complaint, you will not
yet have a case number or assigned judges.)
(Full name(s) of the defendant(s)/respondent(s).)
APPLICATION TO PROCEED WITHOUT PREPAYING FEES OR COSTS
I am a plaintiff/petitioner in this case and declare that I am unable to pay the costs of these proceedings and
I believe that I am entitled to the relief requested in this action. In support of this application to proceed in
forma pauperis (“IFP”) (without prepaying fees or costs), I declare that the responses below are true:
Are you incarcerated?
I am being held at:
Do you receive any payment from this institution?
(If “No,” go to Question 2.)
If I am a prisoner, see 28 U.S.C. § 1915(h), I have attached to this document a “Prisoner
Authorization” directing the facility where I am incarcerated to deduct the filing fee from my account
in installments and to send to the Court certified copies of my account statements for the past six
months. See 28 U.S.C. § 1915(a)(2), (b). I understand that this means that I will be required to pay the
full filing fee.
2. Are you presently employed?
If “yes,” my employer’s name and address are:
Gross monthly pay or wages:
If “no,” what was your last date of employment?
Gross monthly wages at the time:
3. In addition to your income stated above (which you should not repeat here), have you or anyone else
living at the same residence as you received more than $200 in the past 12 months from any of the
following sources? Check all that apply.
(a) Business, profession, or other self-employment
(b) Rent payments, interest, or dividends
SDNY Rev: 12/12/2014
(c) Pension, annuity, or life insurance payments
(d) Disability or worker’s compensation payments
(e) Gifts or inheritances
(f) Any other public benefits (unemployment, social security,
food stamps, veteran’s, etc.)
(g) Any other sources
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.
If you answered “No” to all of the questions above, explain how you are paying your expenses:
How much money do you have in cash or in a checking, savings, or inmate account?
5. Do you own any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other
financial instrument or thing of value, including any item of value held in someone else’s name? If so,
describe the property and its approximate value:
6. Do you have any housing, transportation, utilities, or loan payments, or other regular monthly
expenses? If so, describe and provide the amount of the monthly expense:
7. List all people who are dependent on you for support, your relationship with each person, and how
much you contribute to their support (only provide initials for minors under 18):
8. Do you have any debts or financial obligations not described above? If so, describe the amounts owed
and to whom they are payable:
Declaration: I declare under penalty of perjury that the above information is true. I understand that a false
statement may result in a dismissal of my claims.
Name (Last, First, MI)
Prison Identification # (if incarcerated)
E-mail Address (if available)
IFP Application, page 2
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