Case 1:23-cv-03903-JSR

Document 43-1

Filed 01/12/24

Page 1 of 10

UNITED STATES DISTRICT COUR
SOUTHER [x] DISTRICT T OF

United States District Court Southern District o f Ne w York

Ruby J. Krajick
Clerk of Court

Dear Litigant:

Enclosed is a copy of the judgment entered in your case. If you disagree with a judgment or final order of the district court, you may appeal to the United States Court of Appeals for the Second Circuit. To start this process, file a “Notice of Appeal” with this Court’s Pro Se Intake Unit.

You must file your notice of appeal in this Court within 30 days after the judgment or order that you wish to appeal is entered on the Court’s docket, or, if the United States or its officer or agency is a party, within 60 days after entry of the judgment or order. If you are unable to file your notice of appeal within the required time, you may make a motion for extension of time, but you must do so within 60 days from the date of entry of the judgment, or within 90 days if the United States or its officer or agency is a party, and you must show excusable neglect or good cause for your inability to file the notice of appeal by the deadline.

Please note that the notice of appeal is a one-page document containing your name, a description of the final order or judgment (or part thereof) being appealed, and the name of the court to which the appeal is taken (the Second Circuit) – it does not include your reasons or grounds for the appeal. Once your appeal is processed by the district court, your notice of appeal will be sent to the Court of Appeals and a Court of Appeals docket number will be assigned to your case. At that point, all further questions regarding your appeal must be directed to that court.

The filing fee for a notice of appeal is $605 payable in cash, by bank check, certified check, or money order, to “Clerk of Court, S.D.N.Y.” No personal checks are accepted. Please see District Court fee schedule at https://www.nysd.uscourts.gov/programs/fees. If you are unable to pay the $605 filing fee, complete the “Motion to Proceed in Forma Pauperison Appeal” form and submit it with your notice of appeal to the Pro Se Intake Unit. If the district court denies your motion to proceed in forma pauperis on appeal, or has certified under 28 U.S.C. ' 1915(a)(3) that an appeal would not be taken in good faith, you may file a motion in the Court of Appeals for leave to appeal in forma pauperis, but you must do so within 30 days after service of the district court order that stated that you could not proceed in forma pauperis on appeal.

For additional issues regarding the time for filing a notice of appeal, see Federal Rule of Appellate Procedure 4(a). There are many other steps to beginning and proceeding with your appeal, but they are governed by the rules of the Second Circuit Court of Appeals and the Federal Rules of Appellate Procedure. For more information, visit the Second Circuit Court of Appeals website at http://www.ca2.uscourts.gov/.

THE DANIEL PATRICK MOYNIHAN
UNITED STATES COURTHOUSE
500 PEARL STREET
NEW YORK, NY 10007-1312

THE CHARLES L. BRIEANT, JR.
UNITED STATES COURTHOUSE
300 QUARROPAS STREET
WHITE PLAINS, NY 10601-4150

Rev. 5/23/14

Case 1:23-cv-03903-JSR

Document 43-1

Filed 01/12/24

Page 2 of 10

## UNITED STATES DISTRICT COURT

## SOUTHERN DISTRICT OF NEW YORK

<empty>

(List the full name(s) of the plaintiff(s)/petitioner(s).): <empty> CV <empty> ( ) ( )

-against-

NOTICE OF APPEAL

<empty>

(List the full name(s) of the defendant(s)/respondent(s).

Notice is hereby given that the following parties:
(list the names of all parties who are filing an appeal)
in the above-named case appeal to the United States Court of Appeals for the Second Circuit
from the [ ] judgment [ ] order entered on: <empty> (date that judgment or order was entered on docket)
that:
<empty>
(If the appeal is from an order, provide a brief description above of the decision in the order.)
Dated: <empty>
Signature: <empty>
Name (Last, First, MI): <empty>
Address: <empty>
City: <empty>
State: <empty>
Zip Code: <empty>
Telephone Number: <empty>
E-mail Address (if available): <empty>

*
Each party filing the appeal must date and sign the Notice of Appeal and provide his or her mailing address and telephone
number, EXCEPT that a signer of a pro se notice of appeal may sign for his or her spouse and minor children if they are parties
to the case. Fed. R. App. P. 3(c)(2). Attach additional sheets of paper as necessary.

Rev. 12/23/13

Case 1:23-cv-03903-JSR

Document 43-1

Filed 01/12/24

Page 3 of 10

## UNITED STATES DISTRICT COURT

## SOUTHERN DISTRICT OF NEW YORK

<empty>

(List the full name(s) of the plaintiff(s)/petitioner(s).): <empty> CV <empty> ( ) ( )

-against-

MOTION FOR EXTENSION OF TIME TO FILE NOTICE OF APPEAL

<empty>

(List the full name(s) of the defendant(s)/respondent(s).): <empty>

I move under Rule 4(a)(5) of the Federal Rules of Appellate Procedure for an extension of time to file a notice of appeal in this action. I would like to appeal the judgment entered in this action on <empty> but did not file a notice of appeal within the required date because:

<empty>

(Explain here the excusable neglect or good cause that led to your failure to file a timely notice of appeal.)

Dated: <empty>
Signature: <empty>
Name (Last, First, MI): <empty>
Address: <empty>
City: <empty>
State: <empty>
Zip Code: <empty>
Telephone Number: <empty>
E-mail Address (if available): <empty>

Rev. 3/27/15

Case 1:23-cv-03903-JSR

Document 43-1

Filed 01/12/24

Page 4 of 10

## UNITED STATES DISTRICT COURT

## SOUTHERN DISTRICT OF NEW YORK

<empty>

(List the full name(s) of the plaintiff(s)/petitioner(s).)
<empty> CV <empty> ( <empty> )
-against-
MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS ON APPEAL

(List the full name(s) of the defendant(s)/respondent(s).

I move under Federal Rule of Appellate Procedure 24(a)(1) for leave to proceed in forma

pauperis on appeal. This motion is supported by the attached affidavit.

Dated:<empty>
Signature:<empty>

Name (Last, First, MI):<empty>

Address:<empty>
City:<empty>
State:<empty>
Zip Code:<empty>

Telephone Number:<empty>
E-mail Address (if available):<empty>

Rev. 12/23/13

Case 1:23-cv-03903-JSR

Document 43-1

Filed 01/12/24

Page 5 of 10

# Application to Appeal In Forma Pauperis

<empty> v. <empty>
Appeal No.:<empty>
District Court or Agency No.:<empty>

## Affidavit in Support of Motion

## Instructions

I swear or affirm under penalty of perjury that,
because of my poverty, I cannot prepay the docket
fees of my appeal or post a bond for them. I believe
I am entitled to redress. I swear or affirm under
penalty of perjury under United States laws that my
answers on this form are true and correct. (28
U.S.C. § 1746; 18 U.S.C. § 1621.)

Signed: <empty>

Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is "0," "none," or "not applicable (N/A)," write that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name, your case's docket number, and the question number.

Date: <empty>

My issues on appeal are: (required):

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<br />amount during the past<br />12 months   | Average monthly<br />amount during the past<br />12 months   | Amount expected next<br />month   | Amount expected next<br />month   |
|-|-|-|-|-|
| Income source                                          | You                                                          | Spouse                                                       | You                               | Spouse                            |
| Employment                                             | $                                                            | $                                                            | $                                 | $                                 |
| Self-employment                                        | $                                                            | $                                                            | $                                 | $                                 |
| Income from real property (such as<br />rental income) | $                                                            | $                                                            | $                                 | $                                 |

12/01/2013 SCC

- 1 -

Case 1:23-cv-03903-JSR Document 43-1 Filed 01/12/24 Page 6 of 10

<table><tr><th>Interest and dividends</th><th>$</th><th>$</th><th>$</th><th>$</th></tr><tr><td>Gifts</td><td>$</td><td>$</td><td>$</td><td>GA $</td></tr><tr><td>Alimony</td><td>$</td><td>$</td><td>$</td><td>SA $</td></tr><tr><td>Child support</td><td>$</td><td>$</td><td>$ EA</td><td>SA $</td></tr><tr><td>Retirement (such as social security,
pensions, annuities, insurance)</td><td>$</td><td>$ GA</td><td>$ GA</td><td>$ EA</td></tr><tr><td>Disability (such as social security,
insurance payments)</td><td>$</td><td>$ EA</td><td>SA $</td><td>$</td></tr><tr><td>Unemployment payments</td><td>$</td><td>$</td><td>S</td><td>GA $</td></tr><tr><td>Public-assistance (such as welfare)</td><td>$</td><td>$</td><td>$</td><td>$</td></tr><tr><td>Other (specify):</td><td>$</td><td>$</td><td>S</td><td>SASA</td></tr><tr><td>Total monthly income:</td><td>$0</td><td>$ 0</td><td>$0</td><td>$0</td></tr></table>

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

| Employer   | Address   | Dates of<br />employment   | Gross <br />monthly pay   |
|-|-|-|-|
|            |           |                            | $                         |
|            |           |                            | $                         |
|            |           |                            | $                         |

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<br />employment   | Gross <br />monthly pay   |
|-|-|-|-|
|            |           |                            | $                         |
|            |           |                            | $                         |
|            |           |                            | $                         |

-2-

Case 1:23-cv-03903-JSR

Document 43-1

Filed 01/12/24

Page 7 of 10

4. How much cash do you and your spouse have?: $:<empty>

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   | Amount your<br />spouse has   |
|-|-|-|-|
|                         |                   | $                 | $                             |
|                         |                   | $                 | $                             |
|                         |                   | $                 | $                             |

If you are a prisoner seeking to appeal a judgment in a civil action or proceeding, 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.

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

| Home      | Other real estate   | Motor vehicle #1   |
|-|-|-|
| (Value) $ | (Value) $           | (Value) $          |
|           |                     | Make and year:     |
|           |                     | Model:             |
|           |                     | Registration #:    |

| Motor vehicle #2   | Other assets   | Other assets   |
|-|-|-|
| (Value) $          | (Value) $      | (Value) $      |
| Make and year:     |                |                |
| Model:             |                |                |
| Registration #:    |                |                |

-3-

Case 1:23-cv-03903-JSR

Document 43-1

Filed 01/12/24

Page 8 of 10

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

| Person owing you or your spouse<br />money   | Amount owed to you   | Amount owed to your<br />spouse   |
|-|-|-|
|                                              | $                    | $                                 |
|                                              | $                    | $                                 |
|                                              | $                    | $                                 |
|                                              | $                    | $                                 |

7. State the persons who rely on you or your spouse for support.

| Name [or, if a minor (i.e., underage), initials only]   | Relationship   | Age   |
|-|-|-|
|                                                         |                |       |
|                                                         |                |       |
|                                                         |                |       |

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.

|                                                                                                                                                                                   | You   | Your Spouse   |
|-|-|-|
| Rent or home-mortgage payment (including lot rented for<br />mobile home)<br />Are real estate taxes included? [ ] Yes [ ] No<br />Is property insurance included? [ ] Yes [ ] No | $     | $             |
| Utilities (electricity, heating fuel, water, sewer, and telephone)                                                                                                                | $     | $             |
| Home maintenance (repairs and upkeep)                                                                                                                                             | $     | $             |
| Food                                                                                                                                                                              | $     | $             |
| Clothing                                                                                                                                                                          | $     | $             |
| Laundry and dry-cleaning                                                                                                                                                          | $     | $             |
| Medical and dental expenses                                                                                                                                                       | $     | $             |

- 4-

Case 1:23-cv-03903-JSR

Document 43-1

Filed 01/12/24

Page 9 of 10

<table><tr><th colspan="2">Transportation (not including motor vehicle payments)</th><th>$</th><th>$</th></tr><tr><td colspan="2">Recreation, entertainment, newspapers, magazines, etc.</td><td>$</td><td>$</td></tr><tr><td colspan="4">Insurance (not deducted from wages or included in mortgage payments)</td></tr><tr><td rowspan="5"></td><td>Homeowner's or renter's:</td><td>$</td><td>$</td></tr><tr><td>Life:</td><td>$</td><td>$</td></tr><tr><td>Health:</td><td>$</td><td>$</td></tr><tr><td>Motor vehicle:</td><td>$</td><td>$</td></tr><tr><td>Other:</td><td>$</td><td>$</td></tr><tr><td colspan="2">Taxes (not deducted from wages or included in mortgage
payments) (specify):</td><td>$</td><td>$</td></tr><tr><td colspan="4">Installment payments</td></tr><tr><td></td><td>Motor Vehicle:</td><td>$</td><td>$</td></tr><tr><td></td><td>Credit card (name):</td><td>$</td><td>$</td></tr><tr><td></td><td>Department store (name):</td><td>$</td><td>$</td></tr><tr><td></td><td>Other:</td><td>$</td><td>$</td></tr><tr><td colspan="2">Alimony, maintenance, and support paid to others</td><td>$</td><td>$</td></tr><tr><td colspan="2">Regular expenses for operation of business, profession, or
farm (attach detailed statement)</td><td>$</td><td>$</td></tr><tr><td colspan="2">Other (specify):</td><td>$</td><td>$</td></tr><tr><td colspan="2">Total monthly expenses:</td><td>$ 0</td><td>$ 0</td></tr></table>

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
[ ] No 
If yes, describe on an attached sheet.

10. Have you spent — or will you be spending —any money for expenses or attorney fees in connection with this lawsuit? [ ] Yes [ ] No
If yes, how much? $ <empty>

-5-

Case 1:23-cv-03903-JSR

Document 43-1

Filed 01/12/24

Page 10 of 10

11. Provide any other information that will help explain why you cannot pay the docket fees for your appeal.

12. Identify the city and state of your legal residence.

City:<empty>
State:<empty>
Your daytime phone number::<empty>
Your age::<empty>
Your years of schooling::<empty>
Last four digits of your social-security number::<empty>

Print

Save

Reset Form

-6-
documents/doj-c7e3165a4b7e781e.pdf
{}