Berry v. Pfister et al, No. 4:2021cv01003 - Document 5 (E.D. Mo. 2021)
Court Description: OPINION, MEMORANDUM AND ORDER (See Full Order) IT IS HEREBY ORDERED that Plaintiffs defective application to proceed in forma pauperis [ECF No. 2 ] is DENIED. IT IS FURTHER ORDERED that the Clerk is directed to send Plaintiff copies of the Courts 'Prisoner Civil Rights Complaint' form and the 'Application to Proceed in District Court without Prepaying Fees or Costs' form.IT IS FURTHER ORDERED that Plaintiff must either pay the $402 filing fee or submit the completed Application to Proceed in District Court without Prepaying Fees or Costs, within thirty (30) days of the date of this Order. IT IS FURTHER ORDERED that if Plaintiff files an Application to Proceed in District Court without Prepaying Fees or Costs , he must also file a certified copy of his prison account statement for the six-month period preceding the filing of the complaint. IT IS FURTHER ORDERED that, within thirty (30) days of the date of this Order, Plaintiff shall file an amended com plaint on the Court-provided form and in compliance with the Courts instructions. IT IS FURTHER ORDERED that Plaintiffs motion for appointment of counsel [ECF No. 3 ] is DENIED without prejudice.IT IS FURTHER ORDERED that Plaintiffs motion to brin g forth exhibits A and B [ECF No. 4 ] is GRANTED. IT IS FINALLY ORDERED that if Plaintiff fails to comply with this Order, the Court will dismiss this action without prejudice and without further notice from the Court. (Response to Court due by 12/3/2021). Signed by District Judge Henry Edward Autrey on 11/3/21. (Attachments: # 1 Attachment Prisoner Civil Rights Complaint Form, # 2 Attachment Application to Proceed Without Cost)(EAB)
Download PDF
<![CDATA[
Berry v. Pfister et al Doc. 5 Att. 2 Clear Form UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI _________ DIVISION ______________________________, ) ) ) ) Civil Case No. _______ ) ) ) ) ) Plaintiff, v. ______________________________, Defendant(s). APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Short Form) I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief requested. In support of this application, I answer the following questions under penalty of perjury: 1. If incarcerated. I am being held at: . If employed there, or have an account in the institution, I have attached to this document a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any institutional account in my name. I am also submitting a similar statement from any other institution where I was incarcerated during the last six months. 2. If not incarcerated. If I am employed, my employer’s name and address are: My gross pay or wages are: $ (specify pay period) , and my take-home pay or wages are: $ per . 3. Other Income. In the past 12 months, I have received income from the following sources (check all that apply): (a) (b) (c) (d) (e) (f) Business, profession, or other self-employment Rent payments, interest, or dividends Pension, annuity, or life insurance payments Disability or worker’s compensation payments Gifts or inheritances Any other sources ___ Yes ___ Yes ___ Yes ___ Yes ___ Yes ___ Yes ___ No ___ No ___ No ___ No ___ No ___ No If you answered “Yes” to any question above, describe below or on separate pages each source of money and state the amount that you received and what you expect to receive in the future. Dockets.Justia.com 4. Amount of money that I have in cash or in a checking or savings account: $ . 5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or thing of value that I own, including any item of value held in someone else’s name (describe the property and its approximate value): 6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide the amount of the monthly expense): 7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship with each person, and how much I contribute to their support: 8. Any debts or financial obligations (describe the amounts owed and to whom they are payable): Declaration: I declare under penalty of perjury that the above information is true and understand that a false statement may result in a dismissal of my claims. ______________________________________ Applicant’s Signature ______________________________________ Printed Name ______________________________________ Date
]]>
Some case metadata and case summaries were written with the help of AI, which can produce inaccuracies. You
should read the full case before relying on it for legal research purposes.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
