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Case: 2:13-cv-00652-GCS-MRA Doc #: 2 Filed: 07/10/13 Page: 1 of 5 PAGEID #: 6

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF OHIO

EASTERN DIVISION

Venice Lipscomb,

v.

Selina Miller, et al.,,

Plaintiff

Defendants

:

:

:

:

:

Civil Action 2:13-cv-0652

Judge Smith

Magistrate Judge Abel

DEFICIENCY ORDER

Plaintiff Venice Lipscomb has filed a complaint that fails to meet the requirement

of Rule 8(a), Fed. R. Civ. P. that it contain a "a short and plain statement of the claim

showing that the pleader is entitled to relief." She has neither paid the Court’s $400

filing fee nor moved for leave to proceed in forma pauperis.

Plaintiff Lipscomb is ORDERED to fill out and execute the Non-Prisoner

Declaration in Support of Request to Proceed Without Prepayment of Fees and Costs

within fourteen (14) days of the date of this Order. Failure to either pay the $400 filing

fee or to file a motion to proceed in forma pauperis with a financial affidavit will result in

dismissal of this lawsuit.

s/Mark R. Abel
United States Magistrate Judge

Case: 2:13-cv-00652-GCS-MRA Doc #: 2 Filed: 07/10/13 Page: 2 of 5 PAGEID #: 7

The fee for filing a complaint is $350. If you are unable to pay
that fee, you may execute the following form, asking the Court to
allow you to proceed without the prepayment of fees.

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF OHIO

EASTERN DIVISION

__________________________,

Plaintiff

:
: Case No.
:

v.

Declaration in
Support of Request to
: Proceed Without Prepay-
ment of Fees and Costs

__________________________,

Defendant

:
:

I, ________________________________, am the plaintiff in the
above-entitled case. In support of my motion to proceed without
being required to prepay fees or costs or give security therefor,
I state that because of my poverty I am unable to pay the costs
of said proceedings or to give security therefor; and that I
believe I am entitled to redress.
I declare that the responses which I have made below are true.
1.

____ Yes ____ No

Are you presently employed?
a.

If the answer is yes, state the amount of your salary
and give the name and address of your employer.

Salary - Wages

$____________ ( ) bi-weekly

( ) yearly
( ) monthly
( ) weekly

Employer's name __________________________________
Address __________________________________________

Case: 2:13-cv-00652-GCS-MRA Doc #: 2 Filed: 07/10/13 Page: 3 of 5 PAGEID #: 8

b.

If the answer is no, state the date of last employment
and the amount of the salary you received.

Date of last employment ______________________

Salary - Wages

$____________ ( ) bi-weekly

( ) yearly
( ) monthly
( ) weekly

2.

Have you received within the past 12 months any money from
any of the following sources?
a.
b.
c.
d.
e.

Business, profession, or form of self-employment?
____ Yes
Rent payments, interest or dividends?
No
Pensions, annuities, or life insurance payments?
____ Yes
____ No
Gifts or inheritances?
Social security, supplemental security income, AFDC,
general relief?

____ Yes ____ No

____ Yes ____ No

____ No

____ Yes ____

If the answer to any of the above is yes, describe each
source of money and state the amount received from each
during the past 12 months.

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
3.

Do you own any cash or do you have money in a checking or
savings account?
If the answer is yes, state the total value owned.

____ Yes ____ No

Cash
$_________________
Checking $_________________
$_________________
Savings

4.

Do you own real estate, stocks, bonds, notes, automobiles,
or other valuable property (excluding ordinary household
furnishings or clothing)?
If the answer is yes, describe the property and state its

____ Yes ____ No

2

Case: 2:13-cv-00652-GCS-MRA Doc #: 2 Filed: 07/10/13 Page: 4 of 5 PAGEID #: 9

approximate value.

Make

Autos __________________________
________________________________
Stocks _________________________
________________________________
Bonds __________________________
________________________________
Notes __________________________
Real Estate ____________________
Mortgage

Value
$___________
$___________
$___________
$___________
$____________
$____________
$____________
$_____________
$_____________

5.

6.

Name

List the persons who are dependent upon you for support;
state your relationship to those persons; and indicate how
much you contribute toward their support.
Relationship
_____________
_____________
_____________
_____________
_____________

__________________________
__________________________
__________________________
__________________________
__________________________

Contribution
$___________
$___________
$___________
$___________
$___________

You are single ___, married ___, widowed ___, separated ___,
or divorced ___.
If you are married, is your spouse employed? ____ Yes ____
No
If yes, how much does your spouse earn?

Salary - Wages

( ) yearly

3

Case: 2:13-cv-00652-GCS-MRA Doc #: 2 Filed: 07/10/13 Page: 5 of 5 PAGEID #: 10

$____________ ( ) bi-weekly

( ) monthly
( ) weekly

7.

List all your creditors, including banks, loan companies,
credit companies, charge accounts, medical bills, etc.

Creditors

Apt. or Home _____________
__________________________
__________________________
__________________________
__________________________

Mo. Payment
$___________
$___________
$___________
$___________
$___________
I declare under penalty of perjury that the foregoing is true and
correct.
Signed this ________ day of ____________________, 20___.

Total Debt
$__________
$__________
$__________
$__________
$__________

______________________________
Signature of Plaintiff

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