Moments v. Warden (John Doe) et al

Filing 3

ORDER DIRECTING PAYMENT OF FEE OR IFP APPLICATION & PRISONER AUTHORIZATION: Plaintiff is directed to render payment of the filing fee or submit an IFP application & Prisoner Authorization 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 denied for the purpose of an appeal. See Coppedge v. United States, 369 U.S. 438, 444-45 (1962). Filing Fee due by 10/24/2024. In Forma Pauperis (IFP) Application due by 10/24/2024. Prisoner Authorization Form due by 10/24/2024. (Signed by Judge Laura Taylor Swain on 9/24/2024) (sac)

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF NEW YORK
BETTA MOMENTS,
24-CV-7065 (LTS)

Plaintiff,
-againstWARDEN (JOHN DOE); et al.,

ORDER DIRECTING PAYMENT OF FEES
OR IFP APPLICATION AND PRISONER
AUTHORIZATION

Defendants.
LAURA TAYLOR SWAIN, Chief United States District Judge:
Plaintiff, who is currently incarcerated at Rose M. Singer Center, brings this action pro
se. To proceed with a civil action in this Court, a prisoner must either pay $405.00 in fees – a
$350.00 filing fee plus a $55.00 administrative fee – or, to request authorization to proceed in
forma pauperis (IFP), that is, without prepayment of fees, submit a signed IFP application and a
prisoner authorization. See 28 U.S.C. §§ 1914, 1915. If the Court grants a prisoner’s IFP
application, the Prison Litigation Reform Act requires the Court to collect the $350.00 filing fee
in installments deducted from the prisoner’s account. 1 See 28 U.S.C. § 1915(b)(1). A prisoner
seeking to proceed in this Court without prepayment of fees must therefore authorize the Court
to withdraw these payments from his account by filing a “prisoner authorization,” which directs
the facility where the prisoner is incarcerated to deduct the $350.00 filing fee from the prisoner’s
account in installments and to send to the Court certified copies of the prisoner’s account
statements for the past six months. See 28 U.S.C. § 1915(a)(2), (b).
Plaintiff submitted the complaint without the filing fees or a completed IFP application
and prisoner authorization. Within thirty days of the date of this order, Plaintiff must either pay

1

The $55.00 administrative fee for filing a civil action does not apply to persons granted
IFP status under 28 U.S.C. § 1915.

the $405.00 in fees or submit the attached IFP application and prisoner authorization. If Plaintiff
submits the IFP application and prisoner authorization, they should be labeled with docket
number 24-CV-7065 (LTS). 2
No summons shall issue at this time. If Plaintiff complies with this order, the case shall be
processed in accordance with the procedures of the Clerk’s Office. If Plaintiff fails to comply
with this order within the time allowed, the action will be dismissed.
The Court certifies under 28 U.S.C. § 1915(a)(3) that any appeal from this order would
not be taken in good faith, and therefore IFP status is denied for the purpose of an appeal. Cf.
Coppedge v. United States, 369 U.S. 438, 444–45 (1962) (holding that appellant demonstrates
good faith when seeking review of a nonfrivolous issue).
SO ORDERED.
Dated:

September 24, 2024
New York, New York

/s/ Laura Taylor Swain
LAURA TAYLOR SWAIN
Chief United States District Judge

2

Plaintiff is cautioned that if a prisoner files a federal civil action or appeal that is
dismissed on the grounds that it is frivolous, malicious, or fails to state a claim upon which relief
may be granted, the dismissal is a “strike” under 28 U.S.C. § 1915(g). A prisoner who receives
three “strikes” cannot file federal civil actions IFP as a prisoner, unless he is under imminent
danger of serious physical injury, and he must pay the filing fees at the time of filing any new
action.
2

U NITED S TATES D ISTRICT C OURT
S OUTHERN D ISTRICT OF N EW Y ORK

(full name of the plaintiff or petitioner applying (each person
must submit a separate application))

-against-

CV

(

) (

)

(Provide docket number, if available; if filing this with
your complaint, you will not yet have a docket number.)

(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:
1.

Are you incarcerated?

Yes

No

(If “No,” go to Question 2.)

I am being held at:
Do you receive any payment from this institution?

Yes

No

Monthly amount:
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?

Yes

No

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: 8/5/2015

Yes
Yes

No
No

(c) Pension, annuity, or life insurance payments

Yes

No

(d) Disability or worker’s compensation payments

Yes

No

(e) Gifts or inheritances
(f) Any other public benefits (unemployment, social security,
food stamps, veteran’s, etc.)
(g) Any other sources

Yes

No

Yes

No

Yes

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.

If you answered “No” to all of the questions above, explain how you are paying your expenses:

4.

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.
Dated

Signature

Name (Last, First, MI)

Prison Identification # (if incarcerated)

Address
Telephone Number

City

State
E-mail Address (if available)

IFP Application, page 2

Zip Code

U NITED S TATES D ISTRICT C OURT
S OUTHERN D ISTRICT OF N EW Y ORK

(full name of the plaintiff/petitioner)

CV

-against-

(

)(

(full name(s) of the defendant(s)/respondent(s))

PRISONER AUTHORIZATION
By signing below, I acknowledge that:
(1) because I filed this action as a prisoner, 1 I am required by statute (28 U.S.C. § 1915) to pay
the full filing fees for this case, even if I am granted the right to proceed in forma pauperis
(IFP), that is, without prepayment of fees;
(2) the full $350 filing fee will be deducted in installments from my prison account, even if my
case is dismissed or I voluntarily withdraw it.
I authorize the agency holding me in custody to:
(1) send a certified copy of my prison trust fund account statement for the past six months
(from my current institution or any institution in which I was incarcerated during the past
six months);
(2) calculate the amounts specified by 28 U.S.C. § 1915(b), deduct those amounts from my
prison trust fund, and disburse those amounts to the Court.
This authorization applies to any agency into whose custody I may be transferred and to any
other district court to which my case may be transferred.

Date

Signature

Prison Identification #

Name (Last, First, MI)

Address

1

City

State

Zip Code

A “prisoner” is “any person incarcerated or detained in any facility who is accused of, convicted of,
sentenced for, or adjudicated delinquent for, violations of criminal law or the terms or conditions of
parole, probation, pretrial release, or diversionary program.” 28 U.S.C. § 1915(h).
SDNY Rev. 10/26/16

)

(Provide docket number, if available; if filing this with your
complaint, you will not yet have a docket number.)