Millas v. Wadas

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UNITED STATES DISTRICT COURT
For the Southern District of Illinois
)
Plai ntiff(s)
v.
)
) Case Number:
)
Defendant(s) )
MOTION AND AFFIDAVIT TO PROCEED
IN DISTRICT COURT
WITHOUT PREPAYING FEES OR COSTS
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 motion, I answer the following questions under penalty of perjury:
1. If incarcerated:
A. I am being held at: .
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. NOTE: You must have an
authorized institutional officer complete the last page of this form.
B. I declare one of the following:
__ I have NOT had 3 or more civil actions dismissed as being frivolous, malicious, or for
failure to state a claim and/or received 3 or more “strikes” under 28 U.S.C. § 1915(g).
__ I am proceeding under 28 U.S.C. § 1915(g), based on my claim that I am in imminent
danger of serious physical injury.
2 . If not incarcerated:
A. Are you employed?
B. If employed, my employer’s name and address are:
C. My gross pay or wages are: $ , and my take-home pay or wages are:
$ per (specify pay period) .
0 Yes 0 No
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3. Other Income. In the past 12 months, I have received income from the following sources
(check all that apply):
(a) Business, profession, or other
selfemployment
0 Yes 0 No
(b) Rent payments, interest, or dividends 0 Yes 0 No
(c) Pension, annuity, or life insurance payments 0 Yes 0 No
(d) Disability or worker’s compensation
payments
0 Yes 0 No
(e) Gifts or inheritances 0 Yes 0 No
(f) Any other sources 0 Yes 0 No
If you answered “Yes” to any question above, describe below or on separate pages each
source of money an d state the amount that you received and what you expect to receive in the future.
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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
a pproximate 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. I
understand that a false statement may result in a dismissal of my cl aim s.
Date:
Movant’s sign atu re
Printed na me
AO 240 (Rev. 06/09) Motion to Proceed in District Court Without Prepaying Fees or Costs (Short Form) MODIFIED SDIL (7/2018)
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CERTIFICATION
(TO BE COMPLETED BY AN AUTHORIZED INSTITUTIONAL OFFICER)
Plaintiff/Petitioner:
Institution:
Register Number:
I, , hereby certify that the
(Name and Title of Authorized Officer - please print)
inmate identified above currently has the sum of $ on account at
.
(Institution where confined)
Signature of Authorized Officer
Dated:
PURSUANT TO 28 U.S.C. § 1915(a)(2), PLEASE
ATTACH A COPY OF THE INMATE’S TRUST
FUND ACCOUNT ST ATEMENT
FOR THE PAST SIX MONTHS .
Please mail the statement and this completed form to:
Clerk of Court
United States District Court
Southern District of Illinois
750 Missouri Ave.
East St. Louis, IL 62201
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