FILED UNITED STATES DISTRICT COURT CLERIC EASTERN DISTRICT OF NEW YORK 2:08 pm, Feb 25, 2020 nnne ne nnn nena nnn nn ene nen U.S. DISTRICT COURT ANN MARIE GRUMM, EASTERN DISTRICT OF NEW YORK LONG ISLAND OFFICE Plaintiff, ORDER -against- 20-CV-00294 (GRB) COMMISSIONER OF SOCIAL SECURITY, Defendant. eee ee nnnnnmnn nn ne ne □□□□□□□□□□□□□□□□□□□□□□ enene KX GARY R. BROWN, United States District Judge: On January 16, 2020, Ann Marie Grumm (“plaintiff”) commenced this action against the Commissioner of Social Security (“defendant”) seeking review of the decision of the Administrative Law Judge pursuant to section 205(g) and/or section 1631(c)(3) of the Social Security Act, as amended,

(g) and/or § 1383(c)(3). Accompanying the complaint is an application to proceed in forma pauperis. (See Docket Entry No. 2.) For the reasons that follow, plaintiffs application to proceed in forma pauperis is denied without — prejudice and with leave to renew upon filing the enclosed “Application to Proceed in District Court without Prepaying Fees or Costs (Long Form)” (AO 239). Alternatively, plaintiff may pay the $400.00 filing fee. To qualify for in forma pauperis status, the Supreme Court has long held that “an affidavit is sufficient which states that one cannot because of his poverty pay or give security for the costs [inherent in litigation] and still be able to provide himself and dependents with the necessities of life.” Adkins v. E.. Du Pont De Nemours & Co.,

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(1948) (internal quotation marks omitted). Plaintiff's application does not include sufficient information for the Court to make such finding. Plaintiff avers that she has $350.00 in a checking or savings account and indicates that, in the past twelve (12) months, she has received income from an “annuity [], MetLife, Voya [and]

real estate” as well as from “gifts inheritance.” (/d. J 3(c), (e), 4.) Plaintiff lists the “Met Life Annuity = $6,000”, the “Inherited Annuity = 20,000”, and “1/5 of a house valued at 300,000.00 that is currently in Estate = 60,000.” Ud at 95.) Plaintiff does not report any housing expenses although she provides a residential address of 14 Roxbury Avenue, Oakdale, New _ York, and indicates approximately $600.00 in other regular monthly expenses which appears to be utilities. (/d.46.) Although plaintiff also lists some debts or other financial obligations in response to question 8, the breakdown of such obligations as provided by plaintiff does not add to the amounts reported on the form. (Uad.9 8.) Thus, plaintiff's application raises more questions than it answers. Given that plaintiff has not provided sufficient information for the Court to assess her financial position, the Court finds that plaintiff can best set forth her current financial position on the Application to Proceed in District Court without Prepaying Fees or Costs (Long Form)” (AO 239). Accordingly, plaintiffs application to proceed in forma pauperis is denied without prejudice and with leave to renew upon filing the enclosed “Application to Proceed in District Court without Prepaying Fees or Costs (Long Form)” (AO 239), Alternatively, plaintiff may pay the $400.00 filing fee. Plaintiff shall either file the Long Form or remit the filing fee within two (2) weeks of the date of this Order or this action will be dismissed without prejudice. The Court certifies pursuant to

(a)(3) that any appeal from this Order would not be taken in good faith and therefore in forma pauperis status is denied for the purpose of any appeal. See Coppedge v. United States,

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(1962). The Clerk of the Court is directed to mail a copy of this Order to the pro se plaintiff. SO ORDERED. /s Gary R. Brown GaryR.Brom United States District Judge Dated: February 25, 2020 Central Islip, New York

Page 1 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

a ) Plaintiff/Petitioner ) v. ) Civil Action No. a ) Defendant/Respondent ) 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 Complete all questions in this application and then sign it. that I am unable to pay the costs of these proceedings Do not leave any blanks: if the answer to a question is “0,” and that I am entitled to the relief requested. I declare “none,” or “not applicable (N/A),” write that response. If under penalty of perjury that the information below is | you need more space to answer a question or to explain your true and understand that a false statement may result in answer, attach a separate sheet of paper identified with your a dismissal of my claims. 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 Average monthly income Income amount expected amount during the past 12 next month months | You [Spouse {| You □□□□□□□□□

eB

Page 2 of 5 AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) . Retirement (such as social security, pensions, annuities, insurance)

. Total monthly income: $ 8 0.0018 $

2. List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Pee temperment | □□□□□□ monthly pa

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 Address Dates of employment monthly pa

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 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 □ ferme

Make and year:

Registration #: .

Make and year:

Registration #: pier OR prem □□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ 6. State every person, business, or organization owing you or your spouse money, and the amount owed. Person owing you or your spouse Amount owed to you Amount owed to your spouse mone

7. State the persons who rely on you or your spouse for support. Name (or, if under 18, initials only) Relationship

Page 4 of 5 AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Ferm) □ 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. ee “Saseeae sess FR Are real estate taxes included? Yes O No Is property insurance included? O Yes OJ No is ar □□ wints fonenaneane mmo BiB OSS femme SSSR fsniyosayeeang SOB petcioncemiegmss SO Fearon emt ORB ceainmtanwnmeioes Insurance (not deducted from wages or included in mortgage paymenis) po Homeowner's or renter’s: s fb

Motor vehicle: oe Fas □□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□

Motor vehicle: s

Department store (name): fs mics mamrmonee BR

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 staiement)

Total monthly expenses: s 0.008 0.00

9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? O Yes ONo If yes, describe on an attached sheet. 10. Have you spent — or will you be spending — any money for expenses or attorney fees in conjunction with this lawsuit? OF Yes ONo 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: