UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK DAVID GIBSON, 22-ev-1122 (JGK) Plaintiff, ORDER - against - SUPERINTENDENT BURNETT, ET AL., Defendants. JOHN G. KOELTL, District Judge: The Court is in receipt of the plaintiff's letter dated May 8, 2022. In the letter, the plaintiff appears to allege, among other things, that correctional officers at the Marcy Correctional Facility (“MCF”) violated his rights. These correctional officers are not defendants in this action and the allegations in the May 8, 2022, letter do not appear to relate to the claims in this action. The plaintiff is advised that if he wishes to bring new claims arising from his incarceration at the MCF, including claims arising from the incidents described in the May 8, 2022, letter, the plaintiff should do so in a new complaint in an appropriate court. Because the MCF is in the Northern District of New York, the plaintiff should bring any claims arising from his incarceration at the MCF in the United States District Court for the Northern District of New York (“N.D.N.¥.%}. An N.D.N.Y. complaint form and an N.D.N.Y.
application to proceed without prepaying fees or costs are attached to this Order. On May 13, 2022, the New York State Attorney General filed
a letter attempting to identify the John and Jane Doe defendants described in the plaintiff’s complaint. ECF No. 8. The plaintiff is reminded that, pursuant to the Court’s Order dated March 15, 2022, the plaintiff must file an amended complaint naming the John and Jane Joe defendants by June 13, 2022. The plaintiff is also reminded that he must serve each defendant with a summons and the complaint. See Fed. R. Civ. P. 4. The plaintiff is advised that if he has difficulties serving the defendants, he
may request that the Court issue an order directing the United States Marshals to effect service on the defendants on the plaintiff’s behalf. Any such request should be accompanied by an application to proceed without prepaying fees or costs so that the Court could waive the costs of service. The New York State Attorney General’s May 13, 2022 letter; the Court’s March 15, 2022, Order; an amended complaint form; and an application to proceed in this Court without prepaying fees or costs are attached to this Order.
The Clerk is directed to mail a copy of this Order and its attachments to the plaintiff and to note service on the docket. SO ORDERED. Dated: New York, New York COS Lf May 19, 2022 LVL G ( ,6boq ; 50 “John G. Koeltl United’ States District Judge
3 .
UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK ) Plaintiff(s) ) Civil Case No.: ) Vs. ) CIVIL ) RIGHTS ) COMPLAINT Defendant(s) ) PURSUANT TO 42 U.S.C. § 1983
Plaintiff(s) demand(s) a trial by: oO JURY COURT (Select only one).
Plaintiffs) in the above-captioned action, allege(s) as follows:
JURISDICTION 1. This is a civil action seeking relief and/or damages to defend and protect the rights guaranteed by the Constitution of the United States. This action is brought pursuant to 4? U.S.C. § 1983. The Court has jurisdiction over this action pursuant to 28 U.S.C. §§ 1331, 1343(3) and (4) and 2201. PARTIES 2. Plaintiff: Address:
Additional Plaintiffs may be added on a separate sheet of paper. 3. a. Defendant: Official Position: Address:
b. Defendant: Official Position: Address:
c. Defendant: Official Position: Address:
Additional Defendants may be added on a separate sheet of paper.
4, FACTS Set forth the facts of your case which substantiate your claim of violation of your civil and/or Constitutional rights. List the events in the order they happened, naming defendants involved, dates and places. Note: You must include allegations of wrongful conduct as to EACH and EVERY defendant in your complaint. (You may use additional sheets as necessary).
ee
5. CAUSES OF ACTION Note: You must clearly state each cause of action you assert in this lawsuit.
FIRST CAUSE OF ACTION
SECOND CAUSE OF ACTION
THIRD CAUSE OF ACTION
ce
NN
we
6. PRAYER FOR RELIEF WHEREFORE, plaintiff(s) request(s) that this Court grant the following relief:
□
we on I declare under penalty of perjury that the foregoing is true and correct. DATED:
Signature of Plaintiff(s) (all Plaintiffs must sign)
02/2010
AO 240 (Rev. 07/10) Application to Proceed in District Court Without rrepaying Pees oF Costs (onol Orn)
UNITED STATES DISTRICT COURT for the Northern District of New York
Plaintiff/Petitioner vy. ) Civil Action No.
Defendant/Respondent )
APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Short Form) Iam 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, 1 answer the following questions under penalty of perjury: 1. If incarcerated. | 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. not incarcerated, If 1am employed, my employer’s name and address are:
My gross pay or wages are: § , and my take-home pay or wages are: $ _ per (specify pay period) _ . 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 self-employment O Yes O No (b) Rent paymenis, interest, or dividends O Yes O No (c) Pension, annuity, or life insurance payments O Yes C1 No (d) Disability, or worker’s compensation payments O Yes O No (e) Gifts, or inheritances O Yes O No (f) Any other sources oO Yes tC] No Ifyou 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.
AO 240 (Rey, 07/10) Application to Procees in District Court Without Prepaying Pees OF 0868 (ONOr POrl:)
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 monthiy 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: 1 declare under penalty of perjury that the above information is true and understand that a false staternent may result in a dismissal of my claims.
Date Applicant's signature
— Printedname
- ak > STATE OF NEW YORK OFFICE OF THE ATTORNEY GENERAL LETITIA JAMES DIVISION OF STATE COUNSEL ATTORNEY GENERAL _ LITIGATION BUREAU Writer’s Direct Dial: (212) 416-8665 May 13, 2022 Via ECF Honorable John G. Koeltl United States District Judge Southern District of New York 500 Pearl Street New York, New York 10007 Re: Gibson v. Burnette, 22 Civ. 1122 IGE) Dear Judge Koelt!: I write on behalf of the New York State Attorney General’s Office in response to Your Honor’s March 15, 2022 Order, (Docket No. 3), directing this Office, pursuant to Valentin v. Dinkins, 121 F.3d 72, 75 (2d Cir. 1997) to attempt to identify the Fishkill John and Jane Doe defendants described in Plaintiff's Complaint. Based on the allegations of the Complaint and the information provided to this Office by the New York State Department of Corrections and Community Supervision, we respond as follows: “Defendant No. 3 Deputy of Security John Doe of Fishkill Correctional Facility” appears to be Stephen Urbanski, former Deputy of Security at Fishkill. He can be served at the following address: c/o Office of Counsel, New York State Department of Corrections and Community Supervision, The Harriman State Campus, Building 2, 1220 Washington Avenue, Albany, New York 12226-2050. “Defendant No. 6 Nurse Administrator Jane Doe, Fishkill Correctional Facility” appears to be Nurse Administrator Barbara Furco. She can be served at the following address: Barbara Furco, Nurse Administrator, Fishkill Correctional Facility, 18 Strack Drive, Beacon, NY 12508. Because more than one male Sergeant was on duty at Fishkill on December 13, 2021, the date “Sergeant John Doe” allegedly failed to document Plaintif?s PREA complaint, we have been unable to determine the identity of the person Plaintiff intends to sue as “Defendant No, 5 SRGNT John Doe, Fishkill CF.” Identification may be possible if
28 Liberty St, New York, New York 10005 © Tel.: (212) 416-8610 © Fax: (212) 416-6075 (Net For Service of Papers) WWW.ag.ny.ZoVv
Plaintiff provides a physical description of the Sergeant he intends to sue, or the exact time and location of his alleged report to this Sergeant. This response is based on information available at this time and is not an admission that the identified individuals engaged in the acts alleged or violated Plaintiff's rights. Thank you for your time and consideration in this regard.
Respectfully submitted, vA LAWRENCE Assistant Attorney General Bahiya.Lawrence@ag.ny.gov cc: David Gibson, pro se DIN 15-A-2714 Auburn Correctional Facility _ 135 State Street P.O. Box 618 Auburn, NY 13024 (via First-Class Mail)
28 Liberty St., New York, New York 10005 @ Tel.: (212) 416-8610 @ Fax: (212) 416-6075 (Not For Service of Papers) WWW.ag. ny. gov
DECLARATION OF SERVICE BAHTYA LAWRENCE, pursuant to 28 U.S.C. 1746, declares under penalty of perjury as follows: That on May 13, 2022, I served a copy of a Valentin Order Response addressed to the □
Court in response to ECF Docket Number 3, on the plaintiff by having it mailed via the United States Postal Service to the following address: David Gibson DIN 15-A-2714 Auburn Correctional Facility 135 State Street P.O. Box 618 Auburn, NY 13024 (via First Class Mail} /s/ Bahiya Lawrence Bahiya Lawrence Assistant Attorney General Executed on May 13, 2022
UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK ee DAVID GIBSON, 22-av-1122 (JGR) Plaintiff, ORDER OF SERVICE
- against - SUPERINTENDENT BURNETTE, ET AL., Defendants. □
JOHN G. KOELTL, District Judge: The plaintiff, who is currently incarcerated in Marcy Correctional Facility, paid the filing fees to commence this pro se action. He brings claims under 42 U.S.C. § 1983, alleging that the defendants violated his rights while he was incarcerated at Fishkill Correctional Facility. As set forth below, the Court directs (1) service on the named defendants and (2) the Attorney General for the State of New York to identify the Fishkill John and Jane Doe defendants.
A. Service on Defendants Burnett, Akinyombo, and Lebron
The Clerk of Court is directed to issue summonses as to defendants Superintendent Edward Burnett; A. Akinyombo, Deputy Superintendent of Health Services; and Danielle Lebron, R.N. The plaintiff is directed to serve the summons and complaint on each defendant within 90 days of the issuance of the summonses. If within those 90 days, the plaintiff has not either served the defendants or requested an extension of time to do so, the Court
may dismiss the claims against the defendants under Rules 4 and 41
of the Federal Rules of Civil Procedure for failure to prosecute. B, John and Jane Doe Defendants Under Valentin v. Dinkins, a pro se litigant is entitied toa
assistance from the district court in identifying a defendant. 121
F.3d 72, 76 (2d Cir. 1997). In the complaint, the plaintiff supplies sufficient information to permit the New York State
Department of Corrections and Community Supervision (DOCCS) to
identify Deputy of Security John Doe, Sergeant John Doe, and Nurse
Administrator Jane Doe named in the complaint. It is therefore ordered that the New York State Attorney General, who is the
attorney for and agent of DOCCS, must ascertain the identity and
badge number of each of the John and Jane Doe defendants whom the
plaintiff seeks to sue here and the addresses where these
defendants may be served. The Attorney General must provide this
information to the plaintiff and the Court within sixty days of
the date of this Order. Within thirty days of receiving this information, the plaintiff must file an amended complaint naming the John and Jane Doe defendants. The amended complaint will
replace, not supplement, the original complaint. An amended complaint form that the plaintiff should complete is attached to
this Order. Once the plaintiff has filed an amended complaint, the
Court will screen the amended complaint and, if necessary, issue
an order directing the Clerk of Court to issue summonses for
service on the named John and Jane Doe defendants.
.
C. Local Civil Rule 33.2 Local Civil Rule 33.2, which requires defendants in certain
types of prisoner cases to respond to specific, court-ordered
discovery requests, applies to this action. Those discovery requests are available on the Court's website under “Forms” and
are entitled “Plaintiff’s Local Civil Rule 33.2 Interrogatories and Requests for Production of Documents.” Within 120 days of
service of the complaint, the defendants must serve responses to
these standard discovery requests. In their responses, the
defendants must quote each request verbatim.? CONCLUSION
The Clerk of Court is directed to issue summonses as to
Defendants Burnett, Akinyombo, and Lebron, and to forward the
summons to the plaintiff for service on the defendants. The Clerk of Court is directed to mail a copy of this Order
and the complaint to the New York State Attorney General at: 28
Liberty Street, New York, NY 10005. The Clerk of Court is further directed to mail a copy of this
Order to the plaintiff, together with an information package, and
to note service on the docket, An amended complaint form is
attached.
1 the plaintiff would like copies of these discovery requests before receiving the responses and does not have access to the website, the plaintiff may request them from the Pro Se Intake Unit.
Local Civil Rule 33.2 applies to this action. SO ORDERED. Dated: New York, New York March 15, 2022 LY □ 6 kgelep P“g3dhn G. Koeltl United States District Judge
Sm UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK
CV Write the full name of each plaintiff. (Include case number if one has been assigned} AMENDED against COMPLAINT (Prisoner) i Do you want a jury trial?
[lYes CNo oe
Write the full name of each defendant. If you cannot fit the names of all of the defendants in the space provided, please write “see attached” in the space above and attach an additional sheet of paper with the full list of names. The names {lsted above must be identical to those contained In Section IV.
NOTICE The public can access electronic court files. For privacy and security reasons, papers filed with the court should therefore not contain: an individual's full social security number or full birth date; the full name of a person known to be a minor; or a complete financial account number. A filing may include only: the last four digits of a social security number; the year of an individual's birth; a minor’s initials; and the last four digits of a financial account num ber, See Federal Rule of Civil Procedure 5.2.
Rev, 5/20/16
1 LEGAL BASIS FOR CLAIM State below the federal legal basis for your claim, if known. This form is designed primarily for prisoners challenging the constitutionality of their conditions of confinement, those claims are often brought under 42 U.S.C, § 1983 (against state, county, or municipal defendants) or ina “Bivens” action {against federal defendants). Violation of my federal constitutional rights [] Other: iL, PLAINTIFF INFORMATION Each plaintiff must provide the following information. Attach additional pages if necessary. First Name Middle Initial Last Name
ee State any other names (or different forms of your name} you have ever used, including any name you have used in previously filing a lawsuit.
Prisoner ID # (if you have previously been in another agency's custody, please specify each agency and the ID number (such as your DIN or NYSID) under which you were held) a Current Place of Detention Tan institutional Address County, City State Zip Code Ii, PRISONER STATUS Indicate below whether you are a prisoner or other confined person: (4 Pretrial detainee 0) Civilly committed detainee 1 Immigration detainee ( Convicted and sentenced prisoner [1 Other:
Page 2
TV. DEFENDANT INFORMATION To the best of your ability, provide the following information for each defendant. If the correct information is not provided, it could delay or prevent service of the complaint on the defendant. Make sure that the defendants listed below are identical to those listed in the caption. Attach additional pages as necessary. Defendant 1: First Name Last Name Shield #
Current Job Title (or other identifying information)
Current Work Address County, City State Zip Code Defendant 2: First Name Last Name Shield #
Current Work Address County, City State Zip Code □ Defendant 3: First Name Last Name Shield #
Current Jab Title (or other identifying information) Current Wark Address County, City State Zip Code Defendant 4: First Name Last Name Shield # Current Job Title (or other identifying information} Current Work Address County, City State Zip Code
Page 3
Vv. STATEMENT OF CLAIM Place(s} of occurrence:
Date(s) of occurrence: FACTS: State here briefly the FACTS that support your case. Describe what happened, how you were harmed, and how each defendant was personally involved in the alleged wrongful actions. Attach additional pages as necessary. a i I a i a an a
Page 4
a a an i a
INJURIES: if you were injured as a result of these actions, describe your injuries and what medical treatment, if any, you required and received. a
ar VI RELIEF State briefly what money damages or other relief you want the court to order. i ar ee a
Page 5
VIL PLAINTIEF’S CERTIFICATION AND WARNINGS By signing below, I certify to the best of my knowledge, information, and belief that: (1) the complaint is not being presented for an improper purpose (such as to harass, cause unnecessary delay, or needlessly increase the cost of litigation); (2) the claims are supported by existing law or by a nonfrivolous argument to change existing law; (3) the factual contentions have evidentiary support or, if specifically so identified, will likely have evidentiary support after a reasonable opportunity for further investigation or discovery; and (4) the complaint otherwise complies with the requirements of Federal Rule of Civil Procedure 11. Lunderstand that if I file three or more cases while I am a prisoner that are dismissed as frivolous, malicious, or for failure to state a claim, I may be denied in forma pauperis status in future cases, Lalso understand that prisoners must exhaust administrative procedwres before filing an action in federal court about prison conditions, 42 U.S.C. § 1997e(a), and that my case may be dismissed if I have not exhausted administrative remedies as required. Lagree to provide the Clerk's Office with any changes to my address, I understand that my failure to keep a current address on file with the Clerk's Office may result in the dismissal of my case,
Each Plaintiff rust sign and date the complaint. Attach additional pages if necessary. If seeking to proceed without prepayment of fees, each plaintiff must also submit an IFP application,
ee ee Dated Plaintiff's Signature
First Name Middle Initial Last Name ne Prison Address County, City State Zip Code
Date on which | am delivering this complaint to prison authorities for mailing:
Page 6
SS reremneel eareergsisinamncsi
UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK
ee i No. Write the full name of each plaintiff. (To be filled out by Clerk’s Office) AMENDED -against- COMPLAINT (Prisoner) Do you want a jury trial? □ (]Yes fINo
Write the full name of each defendant. If you cannot fit the names of all of the defendants in the space provided, please write “see attached” in the space above and attach an additional sheet of paper with the full list of names. The names listed above must be identical to those contained in Section lV. □
NOTICE The public can access electronic court files. For privacy and security reasons, papers filed with the court should therefore not contain: an individual's full social security number or full birth date; the full name of a person known to be a minor; or a complete financial account number, A filing may include only: the last four digits of a social security number; the year of an individual’s birth; a minor’s initials; and the last four digits of a financial account number. See Federal Rule of Civil Procedure 5.2.
Rev. 5/6/16
L LEGAL BASIS FOR CLAIM State below the federal legal basis for your claim, if known. This form is designed primarily for prisoners challenging the constitutionality of their conditions of confinement; those claims are often brought under 42 U.S.C. § 1983 (against state, county, or municipal defendants) or ina “Bivens” action (against federal defendants). C1 Violation of my federal constitutional rights Other: IL. PLAINTIFF INFORMATION Each plaintiff must provide the following information. Attach additional pages if necessary.
First Name Middle Initial Last Name
□ State any other names (or different forms of your name} you have ever used, including any name you have used in previously filing a lawsuit.
Prisoner ID # (if you have previously been in another agency's custody, please specify each agency and the ID number (such as your DIN or NYSID) under which you were held)
Current Place of Detention
a institutional Address
County, City State Zip Code lil. PRISONER STATUS Indicate below whether you are a prisoner or other confined person: Pretrial detainee C1 Civilly committed detainee Immigration detainee Convicted and sentenced prisoner L] Other:
IV. DEFENDANT INFORMATION To the best of your ability, provide the following information for each defendant. If the correct information is not provided, it could delay or prevent service of the complaint on the defendant. Make sure that the defendants listed below are identical to those listed in the caption. Attach additional pages as necessary. Defendant 1: First Name Last Name Shield #
Current Work Address County, City State Zip Code Defendant 2: First Name Last Name Shield #
Current Work Address
County, City State Zip Code Defendant 3: First Name Last Name Shield #
Current Job Title {or other identifying information)
County, City State Zip Code Defendant 4: First Name Last Name Shield #
Current Job Title (or other identifying information) nn Current Work Address
County, City State Zip Code
Vv. STATEMENT OF CLAIM Place(s) of occurrence:
Date(s) of occurrence: FACTS: State here briefly the FACTS that support your case. Describe what happened, how you were harmed, and how each defendant was personally involved in the alleged wrongful actions. Attach additional pages as necessary.
te is □
ee Ne
a nn
INJURIES: if you were injured as a result of these actions, describe your injuries and what medical treatment, if any, you required and received. a a en a VI. RELIEF State briefly what money damages or other relief you want the court to order.
□ ee i
i
VII PLAINTIFF’S CERTIFICATION AND WARNINGS By signing below, I certify to the best of my knowledge, information, and belief that: (1) the complaint is not being presented for an improper purpose (such as to harass, cause unnecessary delay, or needlessly increase the cost of litigation); (2) the claims are supported by existing law or by a nonfrivolous argument to change existing law; (3) the factual contentions have evidentiary support or, if specifically so identified, will likely have evidentiary support after a reasonable opportunity for further investigation or discovery; and (4) the complaint otherwise complies with the requirements of Federal Rule of Civil Procedure 11. I understand that if I file three or more cases while I am a prisoner that are dismissed as frivolous, malicious, or for failure to state a claim, 1 may be denied in forma pauperis status in future cases, I also understand that prisoners must exhaust administrative procedures before filing an action in federal court about prison conditions, 42 U.S.C. § 1997e(a), and that my case may be dismissed if I have not exhausted administrative remedies as required. I agree to provide the Clerk's Office with any changes to my address. I understand that my failure to keep a current address on file with the Clerk's Office may result in the dismissal of my case.
Each Plaintiff must sign and date the complaint. Attach additional pages if necessary. if seeking to proceed without prepayment of fees, each plaintiff must also submit an IFP application.
Dated Plaintiff’s Signature
Prison Address
Date on which | am delivering this complaint to prison authorities for mailing:
ESO oe eee eee UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK
{full name of the plaintiff or petitioner applying (each person must submit a separate application)) CV C JC ) -against- {Provide decket number, if available; if filing this with your complaint, you will not yet have a dacket number.}
(full name(s} of the defendant(s}/respondent(s}} APPLICATION TO PROCEED WITHOUT PREPAYING FEES OR COSTS Tam a plaintiff/ petitioner in this case and declare that Iam unable to pay the costs of these proceedings and I believe that I am entitled to the relief requested in this action. In support of this application to proceed in forma pauperis (IFP) (without prepaying fees or costs), I declare that the responses below are true: 1. Are you incarcerated? L] Yes [] No (if“No,” go to Question 2.) Tam being held at: Do you receive any payment from this institution? [] Yes L] No Monthly amount: 1 am a prisoner, see 28 U.S.C. § 1915(h), I have attached to this document a “Prisoner Authorization” directing the facility where I am incarcerated to deduct the filing fee from my account in installments and to send to the Court certified copies of my account statements for the past six months. See 28 USS.C. § 1915(a)(2), (b). l understand that this means that I will be required to pay the full filing fee. 2. Are you presently employed? [] Yes [1 No if “yes,” my employer's name and address are:
Gross monthly pay or wages: If “no,” what was your last date of employment? Gross monthly wages at the time: 3. addition to your income stated above (which you should not repeat here), have you or arryone else living at the same residence as you received more than $200 in the past 12 months from any of the following sources? Check all that apply. (a) Business, profession, or other self-employment [] Yes No (b) Rent payments, interest, or dividends [] Yes [] No
SDNY Rev: 8/5/2045
(c} Pension, annuity, or life insurance payments [|] Yes [| No (d) Disability or worker’s compensation payments L] Yes [] No (e) Gifts or inheritances [] Yes [J] No (f) Any other public benefits (unemployment, social security, Cl Yes Cl No food stamps, veteran's, etc.) (¢) Any other sources {] Yes [] 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.
If you answered “No” to all of the questions above, explain how you ate paying your expenses:
4. How much money do you have in cash or in a checking, savings, or inmate account?
5. Do you own any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or thing of value, including any item of value held in someone else’s name? If so, describe the property and its approximate value:
6. Do you have any housing, transportation, utilities, or loan payments, or other regular monthly expenses? If so, describe and provide the amount of the monthly expense:
7. List all people who are dependent on you for support, your relationship with each person, and how much you contribute to their support (only provide initials for minors under 18):
8. Do you have any debts or financial obligations not described above? If so, describe the amounts owed and to whom they are payable:
Declaration: I declare under penalty of perjury that the above information is true. | understand that a false statement may result in a dismissal of my claims.
Dated Signature □ Name (Last, First, ME} Prison Identification # (if incarcerated)
Address city State Zip Code
Telephone Number E-mail Address (if available}
IFP Application, page 2