Perket, Scot v. VA Tomah, et al.

Filing 4

ORDER on ifp request: Plaintiff Scot Alan Perket to submit $400 filing fee or affidavit of indigency by 11/2/2016. Signed by Magistrate Judge Peter A. Oppeneer on 10/11/2016. (nln),(ps)

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IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WISCONSIN SCOT ALAN PERKET, Plaintiff, ORDER v. Case No. 16-cv-652-wmc VA TOMAH and VA WISCONSIN SYSTEM, Defendants. Plaintiff Scot Alan Perket has filed a proposed civil complaint. Plaintiff has not paid the $400 filing fee nor asked for leave to proceed without prepayment of fees or costs. In the event that plaintiff wishes to proceed without prepayment of the filing fee, the enclosed petition and affidavit must be completed to determine whether plaintiff qualifies as indigent. ORDER IT IS ORDERED that plaintiff Scot Alan Perket may have until November 2, 2016, in which to either pay the $400 filing fee or to submit an affidavit of indigency and return it to the court. If, by November 2, 2016, plaintiff fails to respond to this order, I will assume that plaintiff wishes to withdraw this action voluntarily. In that event, the case will be closed without prejudice to plaintiff filing the case at a later date. Entered this 11th day of October, 2016. BY THE COURT: /s/ PETER OPPENEER Magistrate Judge UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WISCONSIN SCOT ALAN PERKET, ORDER Plaintiff, v. Case No. 16-cv-652-wmc VA TOMAH AND VA WISCONSIN SYSTEM, Defendants. NON-PRISONER REQUEST TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING THE FILING FEE Answer the following questions to the best of your ability. Note: If you do not tell the truth, the court may dismiss your lawsuit. I. Personal Information 1) Are you employed? □Yes □ No 2) Are you married? If “Yes,” is your spouse employed? □ Yes □ Yes □ No □ No 3) Do you have any dependents that you are responsible for supporting? □ Yes □ No If “Yes,” list them below: Name or initials (for minor children only) 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, include any wages, salary, rent, child support, public assistance, unemployment compensation, disability payments, life insurance payments, pensions, annuities, workers' compensation, stock dividends and interest, gifts and inheritance, or other money you receive from any source.) 1) State your total monthly wages or salary? 2) Provide the name and address of your employer(s): $ ______________ ______________________________________________________________ 3) State your spouse's total monthly wages or salary? $ ______________ State the amount of money you have received from any other source in the last twelve months, such as the sources listed above. Please attach an additional sheet if necessary. Source of income Amount ______________________________________________ $ ______________________ ______________________________________________ $ ______________________ III. Expenses - If you are married or have dependents, your expenses should also include your household's expenses. (When calculating household expenses, you may include groceries, clothing, medical costs, utilities that 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 or court-ordered child support $ __________________________________ Credit card payment(s) $ __________________________________ 2) Do you have any other monthly expenses that you have not already listed? □ Yes □ No If “Yes,” list them below: Expense Amount ____________________________ $ __________________________________ ____________________________ $ __________________________________ ____________________________ $ __________________________________ 3) What are your total 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 home(s)? □ Yes If “Yes,” state the approximate value(s). □ No $ ____________________ What is the amount of equity (assessed value of residence minus outstanding mortgage balance) in the home(s)? $ ____________________ 3) Do you have any cash or checking, savings, or other similar accounts? □ Yes □ No If “Yes,” state the total of such sums. $_____________________________ 4) Do you own any other property of value, such as real estate, stocks, bonds, trusts, or individual retirement accounts (e.g., IRA, 401 k), artwork or jewelry? □ Yes □ No If “Yes,” describe the property and the approximate value(s). ________________________________________________________________ V. Other Circumstances - Describe any other financial circumstance(s) that you would like the court to consider when reviewing this petition. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ I, ____________________, declare that I am the plaintiff bringing this complaint. I declare that I am unable to prepay the fee and that I am entitled to the relief sought in the complaint. ___________________________ Date _________________________________________ Signature - Signed Under Penalty of Perjury

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