UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK GERALD F. COLOMBE, Plaintiff, 24-CV-6993 (LTS) -against- ORDER OF DISMISSAL SULLIVAN CORRECTIONAL FACILITY, Defendant. LAURA TAYLOR SWAIN, Chief United States District Judge: Plaintiff, who is proceeding pro se, initiated this action by submitting a letter, dated September 12, 2024, to the court. By order dated September 19, 2024, the Court directed Plaintiff, within thirty days, to submit a completed request to proceed in forma pauperis (“IFP application”) and prisoner authorization or pay the $405.00 in fees required to file a civil action in this court. That order specified that failure to comply would result in dismissal of the complaint. Plaintiff has not filed an IFP application and prisoner authorization or paid the fees. CONCLUSION Accordingly, the complaint is dismissed without prejudice. See

, 1915. Should Plaintiff want to proceed with this action, he may initiate a new civil action by completing the attached complaint form. If he cannot afford the $405.00 in fees, he may submit the attached IFP application. He also may contact the Pro Se Law Clinic, which is run by a private organization called the City Bar Justice Center. A flyer from the City Bar Justice Center is attached to this order, as well as a Limited Scope Legal Assistance Retainer Agreement. The Court certifies under

(a)(3) that any appeal from this order would not be taken in good faith, and therefore IFP status is denied for the purpose of an appeal. Cf. Coppedge v. United States,

(1962) (holding that an appellant demonstrates good faith when he seeks review of a nonfrivolous issue). The Court directs the Clerk of Court to enter judgment in this case. SO ORDERED. Dated: November 15, 2024 New York, New York

/s/ Laura Taylor Swain LAURA TAYLOR SWAIN Chief United States District Judge UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK

CVE Write the full name of each plaintiff. (Include case number if one has been assigned)

-against- COMPLAINT (Prisoner) Do you want a jury trial? 0mNd—MN L1Yes LINo

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 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 number. See Federal Rule of Civil Procedure 5.2.

Rev. 5/20/16

I. 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

(against state, county, or municipal defendants) or ina “Bivens” action (against federal defendants). L] Violation of my federal constitutional rights L] 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

Institutional Address

County, City State Zip Code II. PRISONER STATUS Indicate below whether you are a prisoner or other confined person: L] Pretrial detainee L] Civilly committed detainee L] Immigration detainee L] 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 Job Title (or other identifying information)

Current Work Address

County, City State Zip Code Defendant 2: First Name Last Name Shield #

Current Job Title (or other identifying information)

Current Work Address

County, City State Zip Code Defendant 3: First Name Last Name Shield #

Current Job Title (or other identifying information)

Current Work 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 V. 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. INJURIES: If you were injured as a result of these actions, describe your injuries and what medical treatment, if any, you required and received.

VI. RELIEF State briefly what money damages or other relief you want the court to order. 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, I 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

First Name Middle Initial Last Name

Prison Address

County, City State Zip Code

Date on which I am delivering this complaint to prison authorities for mailing: 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 ( ) ( ) -against- (Provide docket number, if available; if filing this with your complaint, you will not yet have a docket number.) (full name(s) of the defendant(s)/respondent(s)) APPLICATION TO PROCEED WITHOUT PREPAYING FEES OR COSTS I am a plaintiff/petitioner in this case and declare that I am 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? Yes No (If “No,” go to Question 2.) I am being held at: Do you receive any payment from this institution? Yes No Monthly amount: If I am a prisoner, see

(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

(a)(2), (b). I understand that this means that I will be required to pay the full filing fee.

2. Are you presently employed? Yes 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. In addition to your income stated above (which you should not repeat here), have you or anyone 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 (c) Pension, annuity, or life insurance payments L] Yes [] No (d) Disability or worker’s compensation payments L] Yes [] No (e) Gifts or inheritances L] Yes [] No (f) Any other public benefits (unemployment, social security, C Yes C No food stamps, veteran’s, etc.) (g) Any other sources L] 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 are 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. I understand that a false statement may result in a dismissal of my claims.

Dated Signature

Name (Last, First, MI) Prison Identification # {if incarcerated)

Address City State Zip Code

Telephone Number E-mail Address (if available)

IFP Application, page 2

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK

(full name of the plaintiff/petitioner) CV ( JC) -against- (Provide docket number, if available; if filing this with your complaint, you will not yet have a docket number.)

(full name(s) of the defendant(s)/respondent(s)) PRISONER AUTHORIZATION By signing below, I acknowledge that: (1) because I filed this action as a prisoner,! I am required by statute (

) to pay the full filing fees for this case, even if am granted the right to proceed in forma pauperis (IFP), that is, without prepayment of fees; (2) the full $350 filing fee will be deducted in installments from my prison account, even if my case is dismissed or I voluntarily withdraw it. I authorize the agency holding me in custody to: (1) send a certified copy of my prison trust fund account statement for the past six months (from my current institution or any institution in which I was incarcerated during the past six months); (2) calculate the amounts specified by

(b), deduct those amounts from my prison trust fund, and disburse those amounts to the Court. This authorization applies to any agency into whose custody I may be transferred and to any other district court to which my case may be transferred.

Date Signature

Name (Last, First, MI) Prison Identification #

Address City State Zip Code

“prisoner” is “any person incarcerated or detained in any facility who is accused of, convicted of, sentenced for, or adjudicated delinquent for, violations of criminal law or the terms or conditions of parole, probation, pretrial release, or diversionary program.”

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ABOUT THE PROJECT The Federal Pro Se Legal Assistance Project (Fed Pro) provides limited assistance to self- represented litigants (plaintiffs and defendants) with cases involving civil legal matters in the United States District Court for the Southern District of New York (SDNY).

HOW TO SCHEDULE AN APPOINTMENT

To schedule an appointment for assistance with City Bar Justice [m] “a = □□□ Center’s Fed Pro project, you must first complete our online oi Fe ' Poss re toe Intake Form. pag ea e Our online Intake Form is accessible via one of these ap □□ methods: fg Pia o Scan the QR code to the right. 2 i Go to bit.ly/prosesdny [m] Por e Once onthe City Bar Justice Center Federal Pro Se Legal Assistance page, scroll down to " "and then click " "to be taken to the Intake Form. e When the Intake Form asks: "How can we help you", please select "Federal Court Case" from the drop-down menu. The Fed Pro SDNY office will receive your application ONLY if you select "federal court case." If you select anything else, you will need to re-complete your application. Once you complete the form, someone will contact you, usually within five business days, to schedule an appointment. If you are not able to complete the Intake Form, please call (212) 382-4794, leave a detailed message, and wait for us to call you back, typically within five business days.

HOW WE HELP

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CITY BAR CITY BAR JUSTICE CENTER JUSTICE CENTER SDNY Federal Pro Se Legal Assistance Project es

LIMITED SCOPE LEGAL ASSISTANCE RETAINER AGREEMENT This agreement explains the terms of the limited legal assistance that the City Bar Justice Center (“CBJC’”) has agreed to perform for you through its Federal Pro Se Legal Assistance Projects (“Projects”). Writing your name at the end demonstrates your agreement to the terms herein. I. LIMITS OF ASSISTANCE The Projects agree to provide only limited scope legal assistance in connection with your matter. This means that: e You remain a self-represented (pro se) litigant and are responsible for all aspects of your case. CBJC is not your attorney of record in this matter. In the event that you are or become a party to a case in the Eastern District of New York or the Southern District of New York or any other forum, CBJC will not enter an appearance or otherwise act on your behalf without expressly agreeing to do so and entering into a separate signed agreement with you. CBJC has no obligation to enter into any such agreement. e CBJC has sole discretion to determine the specific type of services provided. These services may include providing advice and counsel about your case, explaining court orders and procedures, reviewing and commenting on your drafts, assisting with drafting, and discussing strategy. e This retainer covers this consultation only. CBJC can stop assisting you with this matter at any time for any reason consistent with the New York Rules of Professional Conduct. e CBJC has not agreed to represent or assist you on any other matter in the future. If CBJC does agree to any representation on another matter, then a separate signed retainer agreement will be necessary. e You may request but are not guaranteed subsequent appointments. CBJC will only provide assistance on subsequent appointments if it provides you with confirmation to you of such assistance, via email or otherwise, with such additional assistance governed by the terms of this agreement, including that the assistance is for that consultation only and that CBJC has sole discretion to decide whether it will provide any additional future consultations. e You are responsible for and must meet all deadlines in your case, regardless of whether you are able to have an appointment at the Projects in the Eastern District or the Southern District.

II. FREE ASSISTANCE, NON-ATTORNEY PROVIDERS, AND COMPETENCY CBJC does not charge for this assistance. You may be assisted by law students and/or paralegals under the supervision of an attorney consistent with the Rules of Professional Responsibility. CBJC’s assistance does not guarantee success or any particular outcome but that CBJC will provide competent assistance. III. TERMINATION OF ASSISTANCE Your participation is entirely voluntary, and you are free to stop receiving CBJC’s limited scope assistance at any time. CBJC may stop providing limited assistance at its sole discretion consistent with the New York Rules of Professional Conduct. If CBJC chooses to stop providing limited assistance, it will provide notice by email, mail, or phone. IV. COSTS OF LITIGATION Filing a lawsuit or defending against a case when you are sued can involve costs. You are responsible for all costs, including filing fees. The CBJC will not pay for any costs associated with your case. The Court may allow you to proceed without paying filing fees (this is called “proceeding in forma pauperis”). Whether you are allowed to proceed in forma pauperis is entirely up to the Court. V. CONFIDENTIALITY CBJC will take all reasonable steps to maintain any information you provide as confidential. VI. REVIEW AND CONSENT If you have questions or concerns, please leave a voicemail for the Project at (212) 382- 4794, and someone will call you back to discuss this agreement. By signing and writing today's date below, you indicate that you: have had an opportunity to discuss this agreement with CBJC or another Attorney of your choice; have read and understand this agreement; consent to the terms of this agreement; and understand the possible risks and benefits of proceeding with limited scope assistance.

Signature Date

Please mail these completed forms to the City Bar Justice Center, Pro Se Legal Assistance Project, 40 Foley CITY BAR CITY BAR JUSTICE CENTER JUSTICE CENTER SDNY Federal Pro Se Legal Assistance Project es Name: Date of Birth: Facility: Identification #

How did you hear about our clinic? (circle one) Pro Se Intake Office Website Conference/Hearing with the Judge Pro Se Information Package — Friend/Family Order/Letter from the Judge Other: Do you already have an open case with the federal court? (circle one) Yes No If yes, what is your case number? If yes, which courthouse is it in? (circle one) Manhattan White Plains

Ethnicity? (circle one) Asian/Pacific Islander Hispanic Caucasian Black Middle Eastern Decline to answer African Caribbean Other: Native American South Asian

Gender?

Education level? (circle one) 8'" grade or less GED 2-4 years of college/vocational school Some high school College graduate Decline to answer High school graduate Graduate degree

Please mail these completed forms to the City Bar Justice Center, Pro Se Legal Assistance Project, 40 Foley Square, LL22, New York, NY 10007.

CITY BAR CITY BAR JUSTICE CENTER JUSTICE CENTER SDNY Federal Pro Se Legal Assistance Project es Immigration status? (circle one) U.S. citizen (born in U.S.) Naturalized U.S. citizen Legal Permanent Resident (Born in: ) No lawful status Decline to answer Other:

Marital status? (circle one) Single Married Divorced Separated Widowed Decline to answer

Do you have a disability? (circle all that apply) No Mental health Vision Hearing Mobility Memory Homebound Decline to answer Other: What is your primary language? LGBTQ+? (circle one) Yes No Decline to answer Veteran?

Please mail these completed forms to the City Bar Justice Center, Pro Se Legal Assistance Project, 40 Foley Square, LL22, New York, NY 10007.