Motion to Proceed In Forma Pauperis — Leroy Banks, Petitioner v. Anthony Terry, et al.

No.

20-57??

IN THE

SUPREME COURT OF THE UNITED STATES

4lL^ — PETITIONER

\jYour Name)

■—

Supreme Court, U.S.

FILED

SEP I 4 2020

OFFICE OF THE Cl FRkr

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— RESPONDENT(S)

MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

The petitioner asks leave to file the attached petition for a writ of certiorari

without prepayment of costs and to proceed in forma pauperis.

Please check the appropriate boxes:

□^Petitioner has previously been granted, leave to proceed in forma pauperis in

the following court(s):

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P‘ ghfidr Cmi/rl O-f_________

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□ Petitioner has not previously been granted leave to proceed in forma

pauperis in any other court.

□ Petitioner’s affidavit or declaration in support of this motion is attached hereto.

□ Petitioner’s affidavit or declaration is not attached because the court below

appointed counsel in the current proceeding, and:

□ The appointment was made under the following provision of law:_________

or

□ a copy of the order of appointment is appended.

(Signature)

AFFIDAVIT OR DECLARATION

IN SUPPORT OF MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS

I, L&n%f

TEC- , am the petitioner in the above-entitled case. In support of

my motion to proceed in forma pauperis, I state that because of my poverty I am unable to pay

the costs of this case or to give security therefor; and I believe I am entitled to redress.

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 amount during

the past 12 months

You

Employment

Self-employment

Income from real property

(such as rental income)

Amount expected

next month

Spouse

You

Spouse,

0

V

$__Q_

V

$.

$.

$.

$.

$.

$.

$.

$__ d

$.

7?

$.

$.

$.

'{7

$.

Interest and dividends

$.

Gifts

$.

o

$.

$.

V

$.

Alimony

$.

(L

$.

$.

(?

$.

Child Support

$.

D

$.

$.

Retirement (such as social

security, pensions,

annuities, insurance)

$.

V

$.

$.

$.

$.

$.

$.

$.

Disability (such as social

security, insurance payments)

Unemployment payments

Public-assistance

(such as welfare)

Other (specify):

Total monthly income:

9

9

$.

$.

$.

V

$.

V

$.

V

$__dl

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$.

$.

9

$.

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$.

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$_

2. List your employment history for the past two years, most recent first. (Gross monthly pay

is before taxes or other deductions.)

Employer

Address

w

Dates of

Em payment

\

X

Gross monthly pay

$.

$.

$

X\

X

X

XX

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.)

Address

Employer

Dates of

Emp|oyment

Gross monthly pay

$.

$.

$.

XX

X

4. How much cash do you and your spouse have? $_____ /At/ /fr_______________

Below, state any money you or your spouse have in bg(fik accounts or in any other financial

institution.

Type of account (e.g., checking or savings)

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Amount you have

Amount your spouse has

$

$.

$.

$

$.

$.

5. List the assets, and their values, which you own or your spouse owns. Do not list clothing

and ordinary household furnishings.

□ Home

Value

□ Other real estate

Value

/

V

□ Motor Vehicle #1

Year, make & model__ _

Value______________

□ Other assets

Description _

Value_____

V

/?

□ Motor Vehicle #2

Year, make & model

Value___________

6. State every person, business, or organization owing you or your spouse money, and the

amount owed.

Person owing you or

your spouse money

Amount owed to you

Amount owed to your spouse

$.

$.

$.

$.

$.

4Z

P

$____

7. State the persons who rely on you or your spouse for support. For minor children, list initials

instead of names (e.g. “J.S.” instead of “John Smith”).

Nami

Relationship

Age

u

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, or

annually to show the monthly rate.

You

d

Rent or home-mortgage payment

(include lot rented for mobile home)

Are real estate taxes included? □ Yes □ No

Is property insurance included? □ Yes □ No

Utilities (electricity, heating fuel,

water, sewer, and telephone)

Your spouse

$.

T>

Home maintenance (repairs and upkeep)

$.

Food

$.

V

Clothing

Laundry and dry-cleaning

$.

Medical and dental expenses

$.

D

D

$.

$.

You

Your spouse

Transportation (not including motor vehicle payments)

Recreation, entertainment, newspapers, magazines, etc.

$.

$.

1?

$.

Insurance (not deducted from wages or included in mortgage payments)

$.

V

Health

$.

V

D

Motor Vehicle

$.

1>

Homeowner’s or renter’s

Life

$.

V

Other:

Taxes (not deducted from wages or included in mortgage payments)

(specify):

$.

V

$.

V

$.

Installment payments

Motor Vehicle

Credit card(s)

$.

Department store(s)

V

Other:

£

Alimony, maintenance, and support paid to others

Regular expenses for operation of business, profession,

or farm (attach detailed statement)

Other (specify):

Total monthly expenses:

$.

$.

V

D

'V

$.

9. Do you expect any major changes to your monthly income or expenses or in your assets or

liabilities during the next 12 months?

□ Yes

If yes, describe on an attached sheet.

f

10. Have you paid - or will you be paying - an attorney any money for serVices in connection

with this case, including the completion of this form? □ Yes fflNo

If yes, how much?_________________ .

If yes, state the attorney’s name, address, and telephone number:

11. Have you paid—or will you be paying—anyone other than an attorney (such as a paralegal or

a typist) any money for services in connection with this case, including the completion of this

form?

□ Yes

No

If yes, how much?

If yes, state the person’s name, address, and telephone number:

12. Provide any other information that will help explain why you cannot pay the costs of this case.

I declare under penalty of perjuiy that the foregoing is true and correct.

Executed on:

a

(Signature)

i

sgrsy*. DEPARTMENT OF HUMAN SERVICES

DEPARTMENT OF COMMUNITY HEALTH

DFCS - BIBB CNTY

456 OGLETHORPE STREET

MACON GA 31201

M®?'department of public health

DEPARTMENT of early care and learning

1-877-423-4746

NOTICE OF DECISION

Worker Name: L.Cunningham

Worker Phone Number: (256) 298-9603

Case Number: 118250036

Client ID: 792044471

003078

LEROY BANKS

2029 LOWE ST

MACON GA 31204 -6115

Report Medicaid Fraud: 1-800-533-0686

DATE: 08/30/2020

D9irecLrN°IHouSr' Food Stamp benefits have changed due to the USDA, Food and Nutrition Service (COLA)

Cost of Living Adjustments.

POLICY REFERENCE: 3400

There has been a change in your benefits.

FOOD STAMPS

are still eligible for Food Stamp benefits. You will receive this amount from

You

2020 through October, 2020 unless there is a change in your household circumstances.

October,

For the month of October, 2020 through October, 2020, you will receive $204.00

Food Stamps will change from $194.00 to $204.00 effective 10/01/2020

Your

for the reason(s) listed below.

Month

Change Reason

Policy

October, 2020

Change in income limits

3715

Here are the eligibility decisions for each person included in your benefits:

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Client Name: LEROY BANKS

Food Stamps

Program

Benefit Month(s)

October, 2020 — October, 2020

Client ID: 792044471

Decision

Eligible

DEPARTMENT OF HUMAN SERVICES

DEPARTMENT OF COMMUNITY HEALTH

DEPARTMENT of public health

DEPARTMENT OF EARLY CARE AND LEARNING

DFCS - BIBB CNTY

456 OGLETHORPE STREET

MACON GA 31201

1-877-423-4746

NOTICE OF DECISION

Worker Name: L.Cunningham

Worker Phone Number: (478) 752-1112

Case Number: 118250036

Client ID: 792044471

002562

LEROY BANKS

2029 LOWE ST

MACON GA 31204-6115

Report Medicaid Fraud: 1-800-533-0686

DATE: 05/08/2020

Dear LEROY BANKS

FOOD STAMPS

You are still eligible for Food Stamp benefits. You will continue to receive.benefits in the amount of

$194.00 per month. You will receive this amount from May, 2020 through October, 2020

unless there is a change in your household circumstances.

For the months May, 2020 through October, 2020, you will receive $194.00.

Here are the eligibility decisions for each person included in your benefits:

Client ID: 792044471

Client Name: LEROY BANKS

Program

Food Stamps

Benefit Month(s)

May, 2020

June, 2020 — October, 2020

Decision

Eligible

Eligible

How do I file a fair hearing?

If you disagree with our decision, please see the last two (2) pages of this form for information on

your right to request a fair hearing.

You will not receive a new EBT card. Your current card will still be valid for use. If you have lost

or misplaced your card, please call Conduent Customer Service at 1-888-421-3281 or go to

f* -*-•

iS https://www.connectebt.com/aaebtclient/ to request a replacement card.

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REPORTING CHANGES:

You must report changes in the following situations:

During your Food Stamps/Senior SNAP certification period, you must report if your household’s monthly

gross income goes over $2,082.00. You must report this change within 10 calendar days

following the end of the month the change happens.

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If you fail to report the required changes, you may have to repay any benefits you receive for which

you were not eligible and you may also be prosecuted for fraud.

Page 1 of 4

DFCS - BIBB CNTY

456 OGLETHORPE STREET

MACON GA 31201

1-877-423-4746

DEPARTMENT OF HUMAN SERVICES

DEPARTMENT OF COMMUNITY HEALTH

V* l|f-7 DEPARTMENT OF PUBLIC HEALTH

Kt&y DEPARTMENT OF EARLY CARE AND LEARNING

NOTICE OF Extension of Certification Periods

Case Number: 118250036

Client ID: 792044471

000983

LEROY BANKS

2029 LOWE ST

MACON GA 31204-6115

DATE: 06/26/2020

Report Medicaid Fraud: 1-800-533-0686

Many people throughout the State have been impacted by the COVID-19 Coronavirus Pandemic. Because of this

pandemic, SNAP, Medical Assistance, and TANF households with a certification period ending in March, April, May, or

June 2020 had or will have their certification periods extended for six (6) additional months. These case(s) will not close

for failure to renew your benefits. Do not go to the Gateway website or complete a paper renewal form to complete

your renewal. It has already been completed.

• If your certification ended on March 31,2020, your certification period was extended through September 30, 2020.

• If your certification ended on April 30, 2020, your certification period was extended through October 31, 2020.

• If your certification ended on May 31, 2020, your certification period was extended through November 30, 2020.

• If your certification ends on June 30, 2020, your certification period has been extended through December 31,2020

When your next renewal is due, we will send you a notice to let you know it is time to renew your benefits.

If you have questions about this notice, please contact us by phone at 1-877-423-4746.

Policy Manual Reference for this action is: These are temporary policies and procedures that have been implemented

due to a pandemic or disaster policy will not reflect the temporary policy/

procedural changes.

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£3

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(Rev 06/16)

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