ROSS v. THE COUNTY OF MIDDLESEX et al, No. 3:2016cv00929 - Document 2 (D.N.J. 2016)
Court Description: MEMORANDUM ORDER denying Appellant's Motion to proceed in forma pauperis; Appellant may refile a completed application to proceed in forma pauperis that complies with the instructions provided on the attached form by 7/29/2016; If Appellant does not refile an application to proceed in forma pauperis by 7/29/2016, the Clerk is Ordered to close this case. Signed by Judge Michael A. Shipp on 7/13/2016. (eaj) Modified on 7/13/2016 to indicate IFP is denied (gxh).
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ROSS v. THE COUNTY OF MIDDLESEX et al Doc. 2 UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY In re DAMITREA ANNETTE ROSS, Debtor, Bankruptcy Action No. 15-30789 ON APPEAL FROM THE BANKRUPTCY COURT OF THE DISTRICT OF NEW JERSEY DAMITREA ANNETTE ROSS, Appellant, v. THE COUNTY OF MIDDLESEX, et al., Civil Action No. 16-929 (MAS) MEMORANDUM ORDER ON APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES Appellees. This matter comes before the Court on Appellant Damitrea Annette Ross's ("Appellant") motion to proceed without prepayment of fees under 28 U.S.C. § 1915. (ECF No. 1-4.) Because Appellant did not provide a completed application form, the Court is unable to determine whether Appellant is economically eligible to proceed in forma pauperis. Accordingly, IT IS on this rf'day of July 2016, ORDERED that: 1. Appellant's motion to proceed in forma pauperis (ECF No. 1-4) is DENIED; 2. Appellant may refile a completed application to proceed in forma pauperis that complies with the instructions provided on the form that is attached to this Order by July 29, 2016; and 3. If Appellant does not refile an application to proceed in forma pauperis by July 29, 2016, the Clerk of the Court is ordered to close this case. UNITED STATES DISTRICT JUDGE Dockets.Justia.com Pagel of 5 AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) UNITED STATES DISTRICT COURT for the Plaintiff/Petitioner v. ) ) ) Defendant/Respondent ) ) Civil Action No. 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 that I am unable to pay the costs of these proceedings and that I am entitled to the relief requested. I declare under penalty of perjury that the information below is true and understand that a false statement may result in a dismissal of my claims. Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is "O," "none," or "not applicable (N/A)," write that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your 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 Employment Self-employment Income from real property (such as rental income) Interest and dividends Gifts Alimony Child support Average monthly income amount during the past 12 months Spouse You Income amount expected next month You Spouse $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Page 2 of 5 AO 239 (Rev. Ol/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) Retirement (such as social security, pensions, annuities, Public-assistance (such as welfare) Other (specify): Total monthly income: 2. $ $ $ $ $ $ $ $ $ $ $ $ $ Unemployment payments $ $ Disability (such as social security, insurance payments) $ $ insurance) $ $ $ $ $ $ $ ' List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Gross monthly pay Dates of employment Address $ $ 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 Dates of employment Address 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. Page 3 of 5 AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) 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 money Amount owed to you Amount owed to your spouse $ $ $ $ 7. $ $ State the persons who rely on you or your spouse for support. Name (or, if under 18, initials only) Relationship Age Page 4 of 5 AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) 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. Your spouse You Rent or home-mortgage payment (including lot rented for mobile home) Are real estate taxes included? D Yes D No Is property insurance included? 0 Yes ONo $ $ Utilities (electricity, heatingfuel, 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. $ $ r·· •• 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 . Page 5 of 5 AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) Regular expenses for operation of business, profession, or farm (attach detailed Other (specify): Total monthly expenses: 9. $ $ $ $ Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? 0 Yes 10. $ $ statement) 0 No If yes, describe on an attached sheet. Have you spent- or will you be spending- any money for expenses or attorney fees in conjunction with this lawsuit? 0 Yes 0 No If yes, how much? $ _ _ _ _ _ _ _ __ 11. Provide any other information that will help explain why you cannot pay the costs of these proceedings. 12. Identify the city and state of your legal residence. Your daytime phone number: Your age: _ _ __ Your years of schooling: I j
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