Free Order (PLRA) Missing Documents - District Court of Delaware - Delaware

Case 1:06-cv-00712-SLR Document 3 Filed 12/14/2006 Page1 of4
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
L. THERMOL ROSS, )
Plaintiff, g
v. g Civ. No. 06-712-SLR
JAY PATEL, )
Defendant. )
O R D E R
1. The plaintiff L. Thermol Ross, SBI #156525, a pro
aa litiqant who is presently incarcerated, has filed this action
pursuant to 42 U.S.C. § 1983 without prepayment of the filing fee
or a request to proceed fo forma pauperis.
2. Pursuant to 28 U.S.C. § 1915(b), the plaintiff
shall be assessed the filing fee of $350.00.
3. Pursuant to the requirements of 28 U.S.C.
§ 1915(a)(1) and (2), and in order to determine the schedule of
payment of the filing fee, the plaintiff shall submit to the
Clerk of Court, a request to proceed fo forma pauperis and a
certified copy of his prison trust fund account statement
(memorandum or institutional equivalent, with attachments)
showing all deposits, expenditures and balances durinq the six-
month period immediately precedinq the filing of the complaint,
obtained from the appropriate official at each institution at
which the plaintiff is confined. FAILURE OF THE PLAINTIFF TO
RETURN THE REQUESTED INFORMATION WITHIN 30 DAYS FROM THE DATE

Case 1:06-cv-00712-SLR Document 3 Filed 12/14/2006 Page 2 of 4
THIS ORDER IS SENT SHALL RESULT IN DISMISSAL OF THIS ACTION
WITHOUT PREJUDICE.
4. Unless the Court determines from the plaintiff’s
financial information that he has no assets whatsoever, an
initial partial filing fee of 20 percent (20%) of the greater of
the plaintiff’s average monthly deposit or average monthly
balance in the trust fund account shall be required to paid
before the court reviews the complaint. NOTWITHSTANDING ANY
PAYM NT MADE OR REQUIRED, THE COURT SHALL DISMISS THE CASE IF THE
COURT DETERMINES THAT THE ACTION IS FRIVOLOUS OR MALICIOUS, FAILS
TO STATE A CLAIM UPON WHICH RELIEF MAY BE GRANTED, OR SEEKS
MONETARY RELIEF AGAINST A DEFENDANT WHO IS IMMUNE FROM SUCH
RELIEF.
5. Pursuant to 28 U.S.C. § l9l5(g), if the plaintiff
has had three or more actions dismissed by the Court on the
grounds that they were frivolous, malicious, or failed to state a
claim upon which relief may be granted, then the Court shall deny
the plaintiff leave to proceed in forma pauperis in all future
suits filed without prepayment of the filing fee, unless the
Court determines that the plaintiff is under imminent danger of
serious physical injury.
DATED: !Z·{f'+ /0b
2

Case 1:06-cv-00712-SLR Document 3 Filed 12/14/2006 Page 3 of 4
AO 240 (Rev. I0/(I3)
DELAWARE {Rev. 5/06
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMEN T OF
FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER: O6—7l2 SLR
I, declare that I am the (check appropriate box)
ij Petitioner/Plaintiff/Movant ij Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §I9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
I. Are you currently incarcerated? El Yes ij No (If "No" go to Question 2)
If "YES" state the place ofyour incarceration
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution?
Attach u ledger sheet [rom the institution o[ your incarceration detailing all transactions over the past
six months.
2. Are you currently employed? El Yes El No
a. Ifthe answer is "YES" state the amount ofyour take—home salary or wages and pay period
and give the name and address ofyour employer.
b. Ifthe answer is "NO" state the date ofyour last employment, the amount ofyour take-home
salary or wages and pay period and the name and address ofyour last employer.
3. In the past I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other se|f—employment U Yes U No
b. Rent payments, interest or dividends EJ Yes C1 No
c. Pensions, annuities or life insurance payments U Yes El No
d. Disability or workers compensation payments D Yes C1 No
e. Gifts or inheritances I3 Yes D No
f Any other sources EJ Yes U No
Ifthe answer to any ofthe above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.

Case 1:06-cv-00712-SLR Document 3 Filed 12/14/2006 Page 4 of 4
AO 240 Reverse (Rev. 10/O3)
DELAWARE Rev 5/062
4. D0 y0u have any cash or checking or savings accounts? EI Yes E1 No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
E! Yes Cl No
lf "Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how much you contribute to their support, OR state NONE if applicable.
I declare under penalty of perjury that the above information is true and correct.
DATE SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating all assets. In addition, a prisoner 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.