Roeben, Henry v. Home Depot

Filing 59

ORDER that plaintiff Henry Roeben may have until January 30, 2015, in which to either pay the $505 appellate docketing fee or submit a completed affidavit ofindigency. Signed by Magistrate Judge Peter A. Oppeneer on 1/9/2015. (jef),(ps)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
HENRY ROEBEN,
Plaintiff,

ORDER

v.
Case No. 13-cv-641-wmc
HOME DEPOT, INC.,
Defendant.

Plaintiff Henry Roeben has filed a notice of appeal from the court’s December 29,
2014 order. Plaintiff has neither paid the $505 appellate docketing fee, nor requested leave
to proceed without prepayment of the fee. Assuming that plaintiff wishes to proceed without
prepayment of the fee, plaintiff will be required to complete the enclosed petition and
affidavit to determine whether he qualifies as indigent. If plaintiff does not submit either the
$505 appeal fee or this affidavit by January 30, 2015, his appeal may be dismissed.

ORDER
IT IS ORDERED that plaintiff Henry Roeben may have until January 30, 2015, in
which to either pay the $505 appellate docketing fee or submit a completed affidavit of
indigency. If petitioner fails to pay the $505 appellate docketing fee, comply as directed, or
show cause for failure to do so, then this appeal may be dismissed without further notice.
Entered this 9th day of January, 2015.
BY THE COURT:

/s/
PETER OPPENEER
Magistrate Judge

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF WISCONSIN

______________________________________
Full name of plaintiff(s) or petitioner(s)

Case No. _______________________
(Provided by the clerk of court)

v.
______________________________________
Full name of defendant(s) or respondent(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?

Yes

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)
(b) Are you employed at the institution?

_____________________________
(number)
Yes

No

(c)

Do you receive any payment from the institution?

Yes

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.

Personal Information - continued
2) Are you employed?

Yes

No

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

Yes
Yes

No
No

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

Relationship to You

Only) or Name
Provided

Age

Amoun
t of
Support
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

______________________________________________

$ ______________________

______________________________________________

$ ______________________

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:
Rent or

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?
Yes
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?

Yes

No

If “Yes,” list car(s) below:

Make and Model

Year

Approximate Current Value

_______________________________________________

__________

$___________________________

_______________________________________________

__________

$___________________________

2) Do you own your residence(s)?

Yes

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?
Yes
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?
Yes
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)?
Yes
No
If “Yes,” state the nature of that property and approximate value(s).
____________________________________________________________________________
V. Other Circumstances - Describe any other financial circumstance(s) that you
would like the court to consider when reviewing this petition.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

___________________________
Date
Perjury

_________________________________________
Signature - Signed Under Penalty of