Kriemelmeyer, Frederick v. Krebs, Kevin et al

Filing 2

ORDER directing plaintiff to submit $400 filing fee or an affidavit of indigency by 2/13/2018. Signed by Magistrate Judge Peter A. Oppeneer on 1/23/2018. (jef),(ps)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
FREDERICK GEORGE KRIEMELMEYER,
Plaintiff,

ORDER

v.
Case No. 18-cv-48-bbc
KEVIN KREBS, et al.
Defendants.

Plaintiff Frederick George Kriemelmeyer 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 Frederick George Kriemelmeyer may have until
February 13, 2018, in which to either pay the $400 filing fee or to submit an affidavit of
indigency and return it to the court. If, by February 13, 2018, 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 23rd day of January, 2018.
BY THE COURT:

/s/
PETER OPPENEER
Magistrate Judge

UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
FREDERICK GEORGE KRIEMELMEYER,
Plaintiff,

ORDER

v.
Case No. 18-cv-48-bbc
KEVIN KREBS, et al.
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