Ream, Patricia v. Wittman, Mark
Filing
2
ORDER that appellant is to submit the $298 filing fee or an affidavit of indigency. Financial Affidavit or Filing Fee due 5/27/2014. Signed by Magistrate Judge Peter A. Oppeneer on 5/5/2014. (jef),(ps) Modified docket text on 5/5/2014 (elc).
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
PATRICIA J. REAM,
Appellant,
ORDER
v.
Case No. 14-cv-319-wmc
MARK J. WITTMAN, Trustee,
Appellee.
Appellant Patricia Ream has filed a notice of appeal of an order of the Bankruptcy
Court. She has not paid the $298.00 fee at the Bankruptcy Court for filing an appeal nor has
she requested leave to proceed without prepayment of the fee. Assuming that plaintiff wishes
to proceed without prepayment of the fee, she will be required to complete the enclosed
petition and affidavit to determine whether she qualifies as indigent. If appellant does not
submit this affidavit by May 27, 2014, this case will be dismissed without further notice.
ORDER
IT IS ORDERED that appellant Patricia Ream may have until May 27, 2014, in
which to submit a completed affidavit of indigency. Plaintiff is advised that, if she fails to
comply as directed or show cause of her failure to do so, the court will assume that she does
not wish to proceed and this case will be dismissed without further notice.
Entered this 5th day of May, 2014.
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?
(c)
Do you receive any payment from the institution?
_____________________________
(number)
Yes
No
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.
(WIWD 12/07)
Personal Information - continued
2) Are you employed?
Yes
3) Are you currently married?
Yes
If “Yes,” is your spouse employed?
No
No
Yes
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
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
______________________________________________
$ ______________________
______________________________________________
$ ______________________
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
Make and Model
No
Year
If “Yes,” list car(s) below:
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
_________________________________________
Signature - Signed Under Penalty of Perjury
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