STANLEY A. BOONE, Magistrate Judge.
Plaintiff Gerardo Jaramillo ("Plaintiff") filed a social security complaint on January 13, 2017. (ECF No. 1.) Plaintiff did not pay the filing fee in this action and instead filed an application to proceed in forma pauperis pursuant to 28 U.S.C. § 1915. (ECF No. 2.) However, Plaintiff's application is insufficient for the Court to determine if he is entitled to proceed without prepayment of fees in this action.
The Court may authorize the commencement of an action without prepayment of fees for "a person who submits an affidavit that includes a statement of all assets such person . . . possesses [and] that the person is unable to pay such fees or give security thereof." 28 U.S.C. § 1915(a).
Plaintiff indicates that his mother is dependent on him for support and he states that he contributes fully to her support. However, Plaintiff states that he does not have any cash, checking, or savings accounts, he has nothing of value, he is not currently employed, and the only sources of money he has received in the past 12 months are food stamps and CalFresh. It is unclear how Plaintiff fully supports his mother when he has no assets and has not received any money from any sources in the past 12 months, except for food stamps and CalFresh.
Plaintiff must disclose any financial support he receives from others as part of his in forma pauperis application. All assets and sources of money must be disclosed. An in forma pauperis application must state sufficient information for the Court to determine the ability to pay the costs of litigation.
Accordingly, the Court will order Plaintiff to complete and file an Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) — AO 239. If Plaintiff is unwilling to complete and submit the long form application, Plaintiff must pay the filing fee in full.
Based upon the foregoing, it is HEREBY ORDERED that:
IT IS SO ORDERED.
1. For both you and your spouse estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise.
2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions)
3. List your spouse's employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.)
4. How much cash do you and your spouse have? $ _________________ Below, state any money you or your spouse have in bank accounts or in any other financial institution.
If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account.
5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings.
6. State every person, business, or organization owing you or your spouse money, and the amount owed.
7. State the persons who rely on you or your spouse for support.
8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate.
9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months?
10. Have you paid — or will you be paying — an attorney any money for services in connection with this case, including the completion of this form? □ Yes □ No
If yes, how much? $ _______________
If yes, state the attorney's name, address, and telephone number:
11. Have you paid — or will you be paying — anyone other than an attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion of this form? □ Yes □ No
If yes, how much? $ ___________
If yes, state the person's name, address, and telephone number:
12. Provide any other information that will help explain why you cannot pay the costs of these proceedings.
13. Identify the city and state of your legal residence.
