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Jaramillo v. Commissioner of Social Security, 1:17-cv-00064-SAB. (2017)

Court: District Court, E.D. California Number: infdco20170118a11 Visitors: 22
Filed: Jan. 17, 2017
Latest Update: Jan. 17, 2017
Summary: ORDER REQUIRING PLAINTIFF TO FILE LONG FORM APPLICATION TO PROCEED IN FORMA PAUPERIS (ECF No. 2). 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 entitl
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ORDER REQUIRING PLAINTIFF TO FILE LONG FORM APPLICATION TO PROCEED IN FORMA PAUPERIS

(ECF No. 2).

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:

1. The Clerk of the Court is directed to forward an Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) — AO 239 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) complete and file the enclosed Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) — AO 239; 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: __________________
Source:  Leagle

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