Hurt, Tyrone et al v. Paige, Wade

Filing 2

ORDER that plaintiff is to submit either the $350 filing fee or a financial affidavit by January 24, 2013. Signed by Magistrate Judge Stephen L. Crocker on 1/2/2013. (jef),(ps)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN

TYRONE HURT and
THE AMERICAN PEOPLE OF THE
UNITED STATES OF AMERICA,
Plaintiffs,

ORDER

v.
12-cv-939-bbc
WADE MICHAEL PAIGE,
Defendant.

On December 19, 2012, plaintiff Tyrone Hurt filed a proposed complaint. Plaintiff has
neither paid the $350 filing fee nor submitted the paperwork necessary to support a
determination that he is entitled to proceed without prepaying the filing fee. This court can take
no action in this case until he makes one of these submissions.

ORDER
IT IS ORDERED that plaintiff Tyrone Hurt may have until January 24, 2013, in which
to submit the $350 filing fee for this lawsuit or to submit the enclosed motion to proceed in
forma pauperis and financial affidavit. If, by January 24, 2013, plaintiff fails to submit his $350
payment or the motion for leave to proceed in forma pauperis and financial affidavit, I will assume
that he wishes to withdraw this action voluntarily. In that event, the clerk of court is directed
to close this case without prejudice to plaintiff's filing his case at a later date.

Entered this 2nd day of January, 2013.
BY THE COURT:
/s/
STEPHEN L. CROCKER
Magistrate Judge

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF WISCONSIN
Tyrone Hurt and The American People of the
United States of America.
Full name of plaintiff(s)

Case No.

12-cv-939-bbc
(Provided by the clerk of court)

v.
Wade Michael Paige,
Full name of defendant(s)

PETITION AND AFFIDAVIT TO PROCEED
WITHOUT PREPAYMENT OF FEES AND/OR COSTS
I, ____________________________________________, declare that I am the plaintiff or petitioner
in the above-named action. In support of my request to proceed in forma pauperis, I declare that I
am unable to pay the fees and/or costs of these proceedings and that I am entitled to the relief sought
in the complaint/petition/motion. I answer the following questions truthfully and under penalty of
perjury (additional pages may be added, if necessary, to provide complete information):
I. Personal Information
1) Are you currently incarcerated?

G Yes

G No

If “No,” go to question 2. Complete all sections.
If “Yes,” answer questions (a), (b) & (c), skip to Section IV. Complete sections IV and V.
(a)

State the place of your incarceration and provide your prisoner identification number:
_______________________________________
(place)

_____________________________
(number)

GYes

(b)

Are you employed at the institution?

(c)

Do you receive any payment from the institution? GYes

G No
G No

If you are a prisoner, attach a printout of your prison trust account statement showing transactions
for the six-month period immediately preceding the filing of your complaint, motion, or petition and
showing the balance of your release account. Prisoners who are permitted to file in forma pauperis
must pay the full filing fee in installments.
2

Personal Information - continued
2) Are you employed?

GYes

G No

3) Are you currently married?
If “Yes,” is your spouse employed?

G Yes
G Yes

G No
G No

4) Do you have any legal dependents (children/adults) whom you are responsible for supporting?
G Yes
G No
If “Yes,” list them below:
First and Last Initials (For Minor Children
Only) or Name

Relationship to You

Age

Amount of
Support Provided
Per Month

______________________________

_________________

________

$____________

______________________________

_________________

________

$____________

______________________________

_________________

________

$____________

II. Income - If you are married, your answers must include your spouse's income.
(When calculating income, you must include any salary, child support, public assistance, unemployment
compensation, disability payments, life insurance payments, pensions, annuities, workers' compensation, stock
dividends and interest, gifts, and inheritance, or other incoming monies.)

State your total monthly income?

$ ______________

Provide the name of your employer(s): _______________________________________
State your spouse's total monthly income?

$ ______________

State the amount of money you have received from any other source in the last twelve months
(e.g., rent payments, pension or insurance payments, gifts, inheritance, disability or workers’
compensation payments). Please attach an additional sheet if necessary.
Source of income

Amount

______________________________________________

$ ______________________

______________________________________________

$ ______________________

3

III. Expenses - If you are married and/or have dependents, your expenses should also include your
household's expenses.
(When calculating household expenses, you may include groceries, clothing, medical costs, utilities which are
not included in your rental payments, transportation, and insurance.)

1) Identify the following amounts that you pay per month:
G Rent or

G Mortgage

$ __________________________________

Car payment(s)

$ __________________________________

Alimony and/or court-ordered child support $ __________________________________
Credit card payment(s)

$ __________________________________

2) Do you have any other monthly expenses that you have not already identified?
G Yes
G No
If “Yes,” list them below:
Expense

Amount

__________________________________

$ __________________________________

__________________________________

$ __________________________________

__________________________________

$ __________________________________

3) What is the total amount of your monthly expenses?

$____________________________

IV. Property - If you are married, your answers must include your spouse's property.
1 ) Do you own a car?

G Yes

G No

If “Yes,” list car(s) below:

Make and Model

Year

Approximate Current Value

_______________________________________________

__________

$___________________________

_______________________________________________

__________

$___________________________

4

2) Do you own your residence(s)?

G Yes

G No

If “Yes,” state the approximate value(s). $ ____________________
What is the amount of equity (assessed value of residence minus outstanding
mortgage balance) in the residence(s)? $ ____________________
IV. Property - continued
3) Do you own any other valuable tangible property, including but not limited to, jewelry, artwork,
or antiques?
G Yes
G No
If “Yes,” identify the property and approximate value(s).
Property

Approximate Value

________________________________________________

$______________________

________________________________________________

$______________________

________________________________________________

$______________________

4) Do you have any cash or checking, savings, or other similar accounts? G Yes

G No

If “Yes,” state the total amount of such sums. $ ____________________________________
5) Do you own any intangible property, including but not limited to real estate, stocks, bonds, trusts,
or individual retirement accounts (e.g., IRA, 401 k)?
G Yes
G No
If “Yes,” state the nature of that property and approximate value(s).
____________________________________________________________________________

5

V. Other Circumstances - Describe any other financial circumstance(s) that you would like the
court to consider when reviewing this petition.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

___________________________
Date

_________________________________________
Signature - Signed Under Penalty of Perjury

6