Opinion
ORDER
ALLISON CLAIRE, Magistrate Judge.
Plaintiff, a state prisoner proceeding pro se, has filed a civil rights action pursuant to 42 U.S.C. § 1983, together with a request for leave to proceed in forma pauperis pursuant to 28 U.S.C. § 1915. However, the certificate portion of the request, which must be completed by plaintiff's institution of incarceration, has not been filled out. Also, plaintiff has not filed a certified copy of his prison trust account statement for the six-month period immediately preceding the filing of the complaint. See 28 U.S.C. § 1915(a)(2). Plaintiff will be provided the opportunity to submit a completed in forma pauperis application and a certified copy of his prison trust account statement in support thereof.
In addition, plaintiff has signed and filed a proposed "Order Re. Consent or Request for Reassignment, " which improperly indicates that plaintiff both consents to, and declines, the jurisdiction of the undersigned magistrate judge for all purposes pursuant to 28 U.S.C. § 636(c). Plaintiff will be provided the opportunity to submit a new form containing his signature and assent to only one of these options. Failure to submit a new form will result in the assignment of a district judge and referral to the undersigned magistrate judge for performance of the duties set forth in 28 U.S.C. § 636(b).
In accordance with the above, IT IS HEREBY ORDERED that:
1. Plaintiff shall, within thirty days after the filing date of this order, submit a completed affidavit in support of his request to proceed in forma pauperis on the form provided by the Clerk of Court, including completion of the certificate by an authorized prison official, and a certified copy of his prison trust account statement for the six-month period immediately preceding the filing of the complaint.
2. Plaintiff shall also, within thirty days after the filing date of this order, submit a completed Order Re. Consent or Request for Reassignment, which clearly indicates whether plaintiff consents to, or declines, the jurisdiction of the undersigned magistrate judge for all purposes.
3. The Clerk of the Court is directed to send plaintiff a new Application to Proceed In Forma Pauperis By a Prisoner, and a new Order Re. Consent or Request for Reassignment.
4. Plaintiff's failure to comply with this order may result in a recommendation that this action be dismissed without prejudice.