Lott v. The District Court of Southern District of Ohio et al

Filing 14

DEFICIENCY ORDER: Plf to execute the Non-Prisoner Declaration w/in 28 from the date of this order, failure to do so may result in dismissal of this lawsuit. Signed by Magistrate Judge Mark R. Abel on 8/22/13. (sh1)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION
Harry William Lott,

:
Plaintiff

:
:

v.
The District Court of the Southern
District of Ohio ,

Civil Action 2:13-cv-0562
Judge Marbley

:

Magistrate Judge Abel

:
Defendant
:
DEFICIENCY ORDER
Plaintiff Lott has filed a complaint alleging that he was denied due process of law
in Harry William Lott v. Havar, Inc., et al., Case No. 2:12-cv-608 (S.D. Ohio 2012). He
seeks leave to proceed in forma pauperis; however, he does not support that request with
a financial affidavit demonstrating that he does not have the funds to pay the $350 filing
fee and supplemental $50 filing fee.
Plaintiff Lott is ORDERED to fill out and execute the Non-Prisoner Declaration
in Support of Request to Proceed Without Prepayment of Fees and Costs within
twenty-eight (28) days of the date of this Order. Failure to either pay the $350 filing
fee and supplemental $50 filing fee or to support the motion to proceed in forma pauperis
with a financial affidavit will result in dismissal of this lawsuit.

s/Mark R. Abel
United States Magistrate Judge

The fee for filing a complaint is $350. If you are unable to pay
that fee, you may execute the following form, asking the Court to
allow you to proceed without the prepayment of fees.

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION
__________________________,

:

Plaintiff

:

v.

:
:

__________________________,
Defendant

Case No.
Declaration in
Support of Request to
Proceed Without Prepayment of Fees and Costs

:
:

I, ________________________________, am the plaintiff in the
above-entitled case. In support of my motion to proceed without
being required to prepay fees or costs or give security therefor,
I state that because of my poverty I am unable to pay the costs
of said proceedings or to give security therefor; and that I
believe I am entitled to redress.
I declare that the responses which I have made below are true.
1.

Are you presently employed?
a.

____ Yes

____ No

If the answer is yes, state the amount of your salary
and give the name and address of your employer.
Salary - Wages
( ) yearly
( ) monthly
$____________ ( ) bi-weekly
( ) weekly
Employer's name __________________________________
Address __________________________________________

b.

2.

If the answer is no, state the date of last employment
and the amount of the salary you received.
Date of last employment ______________________
Salary - Wages
( ) yearly
( ) monthly
$____________ ( ) bi-weekly
( ) weekly

Have you received within the past 12 months any money from
any of the following sources?
a.
b.
c.
d.
e.

Business, profession, or form of self-employment?
____ Yes
____ No
Rent payments, interest or dividends?
____ Yes ____
No
Pensions, annuities, or life insurance payments?
____ Yes
____ No
Gifts or inheritances?
____ Yes ____ No
Social security, supplemental security income, AFDC,
general relief?
____ Yes ____ No

If the answer to any of the above is yes, describe each
source of money and state the amount received from each
during the past 12 months.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
3.

Do you own any cash or do you have money in a checking or
savings account?
____ Yes ____ No
If the answer is yes, state the total value owned.
Cash
Checking

$_________________

Savings

4.

$_________________

$_________________

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

Value

Autos __________________________
________________________________

$___________

Stocks _________________________

$___________

________________________________

$___________

Bonds __________________________

$____________

________________________________

$____________

Notes __________________________

$____________

Real Estate ____________________

$_____________

Mortgage
5.

$___________

$_____________

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.
Name

Contribution

__________________________

_____________

$___________

__________________________

_____________

$___________

__________________________

_____________

$___________

__________________________

_____________

$___________

__________________________

6.

Relationship

_____________

$___________

You are single ___, married ___, widowed ___, separated ___,
or divorced ___.
If you are married, is your spouse employed? ____ Yes
No
If yes, how much does your spouse earn?
Salary - Wages
( ) yearly
3

____

$____________
7.

( )
( )
( )

monthly
bi-weekly
weekly

List all your creditors, including banks, loan companies,
credit companies, charge accounts, medical bills, etc.
Total Debt

Mo. Payment

Apt. or Home _____________

$__________

$___________

__________________________

$__________

$___________

__________________________

$__________

$___________

__________________________

$__________

$___________

__________________________

$__________

$___________

Creditors

I declare under penalty of perjury that the foregoing is true and
correct.
Signed this ________ day of ____________________, 20___.

______________________________
Signature of Plaintiff

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