Filed: Jun. 13, 2016
Latest Update: Jun. 13, 2016
Summary: ORDER REQUIRING PLAINTIFF TO FILE LONG FORM APPLICATION (ECF NO. 2) TWENTY DAY DEADLINE STANLEY A. BOONE , Magistrate Judge . Plaintiff Charles Ray Greenlea filed a complaint on June 9, 2016 challenging the Commissioner's denial of Social Security benefits. 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. However, Plaintiff's application was not adequately completed. Plaintiff appeared to respo
Summary: ORDER REQUIRING PLAINTIFF TO FILE LONG FORM APPLICATION (ECF NO. 2) TWENTY DAY DEADLINE STANLEY A. BOONE , Magistrate Judge . Plaintiff Charles Ray Greenlea filed a complaint on June 9, 2016 challenging the Commissioner's denial of Social Security benefits. 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. However, Plaintiff's application was not adequately completed. Plaintiff appeared to respon..
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ORDER REQUIRING PLAINTIFF TO FILE LONG FORM APPLICATION
(ECF NO. 2) TWENTY DAY DEADLINE
STANLEY A. BOONE, Magistrate Judge.
Plaintiff Charles Ray Greenlea filed a complaint on June 9, 2016 challenging the Commissioner's denial of Social Security benefits. 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. However, Plaintiff's application was not adequately completed. Plaintiff appeared to respond that he was receiving money from business, profession or other self-employment, but no such income is reported. 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.
Accordingly, IT IS HEREBY ORDERED that:
1. The Clerk of the Court is directed to forward an in forma pauperis application(Long Form) to Plaintiff;
2. Within twenty (20) days of the date of this order, Plaintiff shall either (1) pay the $400.00 filing fee for this action, or (2) file an application to proceed in forma pauperis without prepayment of the fee; and
3. If Plaintiff fails to comply with this order, this action shall be dismissed.
IT IS SO ORDERED.
UNITED STATES DISTRICT COURT for the Eastern District of California
________________________________________
Plaintiff/Petitioner
v. Civil Action No.
________________________________________
Defendant/Respondent
APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Long Form)
Affidavit in Support of the Application Instructions
I am a plaintiff or petitioner in this case and declare Complete all questions in this application and then sign it.
that I am unable to pay the costs of these proceedings Do not leave any blanks: if the answer to a question is "0,"
and that I am entitled to the relief requested. I declare "none," or "not applicable (N/A)," write that response. If
under penalty of perjury that the information below is you need more space to answer a question or to explain your
true and understand that a false statement may result in answer, attach a separate sheet of paper identified with your
a dismissal of my claims. name, your case's docket number, and the question number.
Signed: __________________________________________ Date:________________
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.
Income source Average monthly income Income amount expected
amount during the past 12 next month
months
You Spouse You Spouse
Employment $ $ $ $
Self-employment $ $ $ $
Income from real property (such as rental income) $ $ $ $
Interest and dividends $ $ $ $
Gifts $ $ $ $
Alimony $ $ $ $
Child support $ $ $ $
Retirement (such as social security, pensions, annuities, $ $ $ $
insurance)
Disability (such as social security, insurance payments) $ $ $ $
Unemployment payments $ $ $ $
Public-assistance (such as welfare) $ $ $ $
Other (specify): $ $ $ $
Total monthly income: $ 0.00 $ 0.00 $ 0.00 $ 0.00
2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.)
Employer Address Dates of employment Gross
monthly pay
$
$
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.)
Employer Address Dates of employment Gross
monthly pay
$
$
$
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.
Financial institution Type of account Amount you have Amount your
spouse has
$ $
$ $
$ $
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.
Assets owned by you or your spouse
Home (Value) $
Other real estate (Value) $
Motor vehicle # 1 (Value) $
Make and year:
Model:
Registration #:
Motor vehicle # 2 (Value) $
Make and year:
Model:
Registration #:
Other assets (Value) $
Other assets (Value) $
6. State every person, business, or organization owing you or your spouse money, and the amount owed.
Person owing you or your spouse Amount owed to you Amount owed to your spouse
money
$ $
$ $
$ $
7. State the persons who rely on you or your spouse for support.
Name (or, if under 18, initials only) Relationship Age
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.
You Your spouse
Rent or home-mortgage payment (including lot rented for mobile home)
Are real estate taxes included? [] Yes [] No $ $
Is property insurance included? [] Yes [] No
Utilities (electricity, heating fuel, water, sewer, and telephone) $ $
Home maintenance (repairs and upkeep) $ $
Food $ $
Clothing $ $
Laundry and dry-cleaning $ $
Medical and dental expenses $ $
Transportation (not including motor vehicle payments) $ $
Recreation, entertainment, newspapers, magazines, etc. $ $
Insurance (not deducted from wages or included in mortgage payments)
Homeowner's or renter's: $ $
Life: $ $
Health: $ $
Motor vehicle: $ $
Other: $ $
Taxes (not deducted from wages or included in mortgage payments) (specify):
Installment payments
Motor vehicle: $ $
Credit card (name): $ $
Department store (name): $ $
Other: $ $
Alimony, maintenance, and support paid to others $ $
Regular expenses for operation of business, profession, or farm (attach detailed $ $
statement)
Other (specify): $ $
Total monthly expenses: $ 0.00 $ 0.00
9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months?
[] Yes [] No If yes, describe on an attached sheet.
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.
Your daytime phone number: __________________
Your age: ________ Your years of schooling: __________
Last four digits of your social-security number: _________
