Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_08-cv-02361/USCOURTS-azd-2_08-cv-02361-0/pdf.json

Nature of Suit Code: 550
Nature of Suit: Prisoner - Civil Rights (U.S. defendant)
Cause of Action: 28:1983 Civil Rights

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JDDL

MDR

WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Scott Riley Dolezal, 

Plaintiff, 

vs.

Vice Chief Justice Berch, Arizona

Supreme Court; et al., 

Defendants. 

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No. CV 08-2361-PHX-DGC (LOA)

ORDER

On December 29, 2008, Plaintiff Scott Riley Dolezal, who is confined in the Maricopa

County Towers Jail, filed a document entitled “Claim for Relief” (Doc. #1), a “Request to

Proceed In Forma Pauperis” (Doc. #3), and a “Declaration in Support of Request to Proceed

In Forma Pauperis (Doc. #4).

I. Request to Proceed In Forma Pauperis and Claim for Relief

It is unclear whether Plaintiff intended to file his case as a civil rights lawsuit or a

habeas corpus petition. In either situation, however, Plaintiff was required to use a courtapproved form when seeking to proceed in forma pauperis and a court-approved form when

filing a civil rights lawsuit or a habeas corpus petition. See LRCiv. 3.4(a) and 3.5(a). He did

not do so. Therefore, the Court will deny without prejudice the Request to Proceed and will

dismiss without prejudice Plaintiff’s “Claim for Relief.” The Court will give Plaintiff 30

days to determine whether he intends to file a civil rights lawsuit or a habeas corpus petition,

either pay the appropriate filing fee or complete the appropriate Application to Proceed In

Forma Pauperis, and file an amended complaint or amended petition on the appropriate

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 1 of 34
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JDDL - 2 -

court-approved form. The Court will direct the Clerk of Court to provide Plaintiff with the

court-approved forms.

II. Leave to Amend

Regardless of whether Plaintiff treats this lawsuit as a civil rights action or a habeas

corpus petition, he is advised that the amended complaint or amended petition must be

retyped or rewritten in its entirety on the court-approved form and may not incorporate any

part of the original “Claim for Relief” by reference. Any amended complaint or amended

petition submitted by Plaintiff should be clearly designated as such on the face of the

document. 

An amended complaint or amended petition supersedes the “Claim for Relief.” Ferdik

v. Bonzelet, 963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. Richard Feiner &

Co., Inc., 896 F.2d 1542, 1546 (9th Cir. 1990). After amendment, the original pleading is

treated as nonexistent. Ferdik, 963 F.2d at 1262. Thus, grounds for relief alleged the “Claim

for Relief” which are not alleged in an amended complaint or amended petition are waived.

King v. Atiyeh, 814 F.2d 565, 567 (9th Cir. 1987).

In determining whether to treat this lawsuit as a civil rights action or a habeas corpus

petition, Plaintiff should take note that 

[f]ederal law opens two main avenues to relief on complaints

related to imprisonment: a petition for habeas corpus, 28 U.S.C.

§ 2254, and a complaint under . . . 42 U.S.C. § 1983. Challenges

to the validity of any confinement or to particulars affecting its

duration are the province of habeas corpus; requests for relief

turning on circumstances of confinement may be presented in a

§ 1983 action.

Muhammad v. Close, 540 U.S. 749, 750 (2004) (citation omitted). In addition, “a state

prisoner’s § 1983 action is barred (absent prior invalidation)–no matter the relief sought

(damages or equitable relief), no matter the target of the prisoner’s suit (state conduct leading

to conviction or internal prison proceedings)–if success in that action would necessarily

demonstrate the invalidity of confinement or its duration.” Wilkinson v. Dotson, 544 U.S.

74, 81-82 (2005). 

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 2 of 34
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Federal courts have jurisdiction over applications of a writ of habeas corpus by

individuals “in custody pursuant to the judgment of a State court” who have first “exhausted

the remedies available in the courts of the State.” 28 U.S.C. § 2254 (emphasis added). Thus,

if Plaintiff is a pretrial detainee, relief would be unavailable pursuant to 28 U.S.C. § 2254.

Section 2241, 28 U.S.C., provides an avenue for habeas corpus relief for a pretrial detainee

in custody in violation of the Constitution or laws and treaties of the United States. “As an

exercise of judicial restraint, however, federal courts elect not to entertain habeas corpus

challenges to state court proceedings until habeas petitioners have exhausted state avenues

for raising [a] federal claim.” Carden v. Montana, 626 F.2d 82, 83 (9th Cir. 1980).

Moreover, the abstention doctrine set forth in Younger v. Harris, 401 U.S. 37 (1971),

prevents a federal court in most circumstances from directly interfering with ongoing

criminal proceedings in state court. 

III. Warnings

A. Address Changes

Plaintiff must file and serve a notice of a change of address in accordance with Rule

83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion for other

relief with a notice of change of address. Failure to comply may result in dismissal of this

action.

B. Copies

Plaintiff must submit an additional copy of every filing for use by the Court. See

LRCiv 5.4. Failure to comply may result in the filing being stricken without further notice

to Plaintiff.

C. Possible Dismissal

If Plaintiff fails to timely comply with every provision of this Order, including these

warnings, the Court may dismiss this action without further notice. See Ferdik, 963 F.2d at

1260-61 (a district court may dismiss an action for failure to comply with any order of the

Court).

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 3 of 34
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IT IS ORDERED:

(1) Plaintiff’s “Claim for Relief” (Doc. #1) is denied without prejudice.

(2) Plaintiff’s Request to Proceed In Forma Pauperis (Doc. #3) is denied without

prejudice.

(3) Within 30 days of the date this Order is filed, Plaintiff must determine whether

he intends to treat this lawsuit as a civil rights lawsuit or a habeas corpus petition.

(a) If Plaintiff treats his lawsuit as a civil rights lawsuit, within 30 days of

the date this Order is filed, Plaintiff must:

(1) either pay the $350.00 filing fee or file a complete Application

to Proceed In Forma Pauperis and a certified six-month trust account

statement, and 

(2) file a first amended complaint on the court-approved form.

(b) If Plaintiff treats his lawsuit as a habeas corpus petition, within 30

days of the date this Order is filed, Plaintiff must:

(1) either pay the $5.00 filing fee or file a complete Application to

Proceed In Forma Pauperis, and

(2) file an amended petition on the court-approved form.

(4) If Plaintiff fails to either pay the appropriate filing fee or file the appropriate,

complete Application to Proceed In Forma Pauperis within 30 days, the Clerk of Court must

enter a judgment of dismissal of this action without prejudice and without further notice to

Plaintiff.

(5) If Plaintiff fails to file either an amended complaint or an amended petition on

the appropriate court-approved form within 30 days, the Clerk of Court must enter a judgment

of dismissal of this action, without prejudice and without further notice to Plaintiff.

(6) The Clerk of Court must mail Petitioner a court-approved form for filing (1) an

an Application to Proceed In Forma Pauperis (Non-Habeas), (2) an Application to Proceed

In Forma Pauperis (Habeas), (3) a civil rights complaint by a prisoner, and (4) a Petition

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 4 of 34
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Under 28 U.S.C. § 2254 for Writ of Habeas Corpus by a Person in State Custody (Non-Death

Penalty).

DATED this 4th day of February, 2009.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 5 of 34
Revised 3/9/07 1

Instructions for a Prisoner Filing a Civil Rights Complaint 

in the United States District Court for the District of Arizona

1. Who May Use This Form. The civil rights complaint form is designed to help incarcerated

persons prepare a complaint seeking relief for a violation of their federal civil rights. These

complaints typically concern, but are not limited to, conditions of confinement. This form

should not be used to challenge your conviction or sentence. If you want to challenge a state

conviction or sentence, you should file a petition under 28 U.S.C. § 2254 for a writ of habeas

corpus by a person in state custody. If you want to challenge a federal conviction or sentence,

you should file a motion under 28 U.S.C. § 2255 to vacate sentence in the federal court that

entered the judgment. 

2. The Form. Local Rule of Civil Procedure (LRCiv) 3.4(a) provides that complaints by

incarcerated persons must be filed on the court-approved form. The form must be typed or

neatly handwritten. The form must be completely filled in to the extent applicable. All

questions must be answered clearly and concisely in the appropriate space on the form. If

needed, you may attach additional pages, but no more than fifteen additional pages, of standard

letter-sized paper. You must identify which part of the complaint is being continued and

number all pages. If you do not fill out the form properly, you will be asked to submit additional

or corrected information, which may delay the processing of your action. You do not need to

cite law. 

3. Your Signature. You must tell the truth and sign the form. If you make a false statement of

a material fact, you may be prosecuted for perjury.

4. The Filing Fee. The filing fee for this action is $350.00. If you are unable to immediately

pay the filing fee, you may request leave to proceed in forma pauperis. Please review the

“Information for Prisoners Seeking Leave to Proceed with a (Non-Habeas) Civil Action in

Federal Court In Forma Pauperis Pursuant to 28 U.S.C. § 1915” for additional instructions.

5. Original and Judge’s Copy. You must send an original plus one copy of your complaint and

of any other documents submitted to the Court. You must send one additional copy to the Court

if you wish to have a file-stamped copy of the document returned to you. All copies must be

identical to the original. Copies may be legibly handwritten.

6. Where to File. You should file your complaint in the division where you were confined

when your rights were allegedly violated. See LRCiv 5.1(a) and 77.1(a). If you were confined

in Maricopa, Pinal, Yuma, La Paz, or Gila County, file in the Phoenix Division. If you were

confined in Apache, Navajo, Coconino, Mohave, or Yavapai County, file in the Prescott

Division. If you were confined in Pima, Cochise, Santa Cruz, Graham, or Greenlee County, file

in the Tucson Division. Mail the original and one copy of the complaint with the $350 filing

fee or the application to proceed in forma pauperis to:

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 6 of 34
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Phoenix & Prescott Divisions: OR Tucson Division:

U.S. District Court Clerk U.S. District Court Clerk

U.S. Courthouse, Suite 130 U.S. Courthouse, Suite 1500

401 West Washington Street, SPC 10 405 West Congress Street

Phoenix, Arizona 85003-2119 Tucson, Arizona 85701-5010

7. Change of Address. You must immediately notify the Court and the defendants in writing

of any change in your mailing address. Failure to notify the Court of any change in your

mailing address may result in the dismissal of your case.

8. Certificate of Service. You must furnish the defendants with a copy of any document you

submit to the Court (except the initial complaint and application to proceed in forma pauperis).

Each original document (except the initial complaint and application to proceed in forma

pauperis) must include a certificate of service on the last page of the document stating the date

a copy of the document was mailed to the defendants and the address to which it was mailed.

See Fed. R. Civ. P. 5(a), (d). Any document received by the Court that does not include a

certificate of service may be stricken. A certificate of service should be in the following form:

I hereby certify that a copy of the foregoing document was mailed

this (month, day, year) to:

Name: 

Address: 

 Attorney for Defendant(s)

 

(Signature)

9. Amended Complaint. If you need to change any of the information in the initial complaint,

you must file an amended complaint. The amended complaint must be written on the courtapproved civil rights complaint form. You may file one amended complaint without leave

(permission) of Court before any defendant has answered your original complaint. See Fed. R.

Civ. P. 15(a). After any defendant has filed an answer, you must file a motion for leave to

amend and lodge (submit) a proposed amended complaint. LRCiv 15.1. In addition, an

amended complaint may not incorporate by reference any part of your prior complaint. LRCiv

15.1(a)(2). Any allegations or defendants not included in the amended complaint are

considered dismissed. All amended complaints are subject to screening under the Prison

Litigation Reform Act; screening your amendment will take additional processing time.

10. Exhibits. You should not submit exhibits with the complaint or amended complaint.

Instead, the relevant information should be paraphrased. You should keep the exhibits to use

to support or oppose a motion to dismiss, a motion for summary judgment, or at trial.

11. Letters and Motions. It is generally inappropriate to write a letter to any judge or the staff

of any judge. The only appropriate way to communicate with the Court is by filing a written

pleading or motion.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 7 of 34
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12. Completing the Civil Rights Complaint Form.

HEADING:

1. Your Name. Print your name, prison or inmate number, and institutional mailing

address on the lines provided.

2. Defendants. If there are four or fewer defendants, print the name of each. If you

name more than four defendants, print the name of the first defendant on the first line,

write the words “and others” on the second line, and attach an additional page listing the

names of all of the defendants. Insert the additional page after page 1 and number it “1-

A” at the bottom.

3. Jury Demand. If you want a jury trial, you must write “JURY TRIAL DEMANDED”

in the space below “CIVIL RIGHTS COMPLAINT BY A PRISONER.” Failure to do

so may result in the loss of the right to a jury trial. A jury trial is not available if you are

seeking only injunctive relief.

Part A. JURISDICTION:

1. Nature of Suit. Mark whether you are filing the complaint pursuant to 42 U.S.C.

§ 1983 for state, county, or city defendants; “Bivens v. Six Unknown Federal Narcotics

Agents” for federal defendants; or “other.” If you mark “other,” identify the source of

that authority. 

2. Location. Identify the institution and city where the alleged violation of your rights

occurred. 

3. Defendants. Print all of the requested information about each of the defendants in the

spaces provided. If you are naming more than four defendants, you must provide the

necessary information about each additional defendant on separate pages labeled “2-A,”

“2-B,” etc., at the bottom. Insert the additional page(s) immediately behind page 2.

Part B. PREVIOUS LAWSUITS:

You must identify any other lawsuit you have filed in either state or federal court while

you were a prisoner. Print all of the requested information about each lawsuit in the spaces

provided. If you have filed more than three lawsuits, you must provide the necessary

information about each additional lawsuit on a separate page. Label the page(s) as “2-A,” “2-

B,” etc., at the bottom of the page and insert the additional page(s) immediately behind page 2.

Part C. CAUSE OF ACTION:

You must identify what rights each defendant violated. The form provides space to

allege three separate counts (one violation per count). If you are alleging more than three

counts, you must provide the necessary information about each additional count on a separate

page. Number the additional pages “5-A,” “5-B,” etc., and insert them immediately behind page

5. Remember that you are limited to a total of fifteen additional pages.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 8 of 34
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1. Counts. You must identify which civil right was violated. You may allege the

violation of only one civil right per count.

2. Issue Involved. Check the box that most closely identifies the issue involved in your

claim. You may check only one box per count. If you check the box marked “Other,”

you must identify the specific issue involved.

3. Supporting Facts. After you have identified which civil right was violated, you must

state the supporting facts. Be as specific as possible. You must state what each

individual defendant did to violate your rights. If there is more than one defendant, you

must identify which defendant did what act. You also should state the date(s) on which

the act(s) occurred, if possible.

4. Injury. State precisely how you were injured by the alleged violation of your rights.

5. Administrative Remedies. You must exhaust any available administrative remedies

before you file a civil rights complaint. See 42 U.S.C. § 1997e. Consequently, you

should disclose whether you have exhausted the inmate grievance procedures or

administrative appeals for each count in your complaint. If the grievance procedures

were not available for any of your counts, fully explain why on the lines provided.

Part D. REQUEST FOR RELIEF:

Print the relief you are seeking in the space provided. 

SIGNATURE:

You must sign your name and print the date you signed the complaint. Failure to sign

the complaint will delay the processing of your action. Unless you are an attorney, you may not

bring an action on behalf of anyone but yourself.

FINAL NOTE

You should follow these instructions carefully. Failure to do so may result in your

complaint being stricken or dismissed. All questions must be answered concisely in the proper

space on the form. If you need more space, you may attach no more than fifteen additional

pages. But the form must be completely filled in to the extent applicable. If you attach

additional pages, be sure to identify which section of the complaint is being continued and

number the pages.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 9 of 34
Revised 3/9/07 1 550/555

Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

(Failure to notify the Court of your change of address may result in dismissal of this action.) 

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

)

 , )

(Full Name of Plaintiff) Plaintiff, )

)

 vs. ) CASE NO. 

) (To be supplied by the Clerk)

(1) , )

(Full Name of Defendant) )

(2) , )

) CIVIL RIGHTS COMPLAINT

(3) ,) BY A PRISONER

)

(4) , ) G Original Complaint

Defendant(s). ) G First Amended Complaint

G Check if there are additional Defendants and attach page 1-A listing them. ) G Second Amended Complaint

A. JURISDICTION

1. This Court has jurisdiction over this action pursuant to:

G 28 U.S.C. § 1343(a); 42 U.S.C. § 1983

G 28 U.S.C. § 1331; Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971).

G Other: .

2. Institution/city where violation occurred: .

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 10 of 34
2

B. DEFENDANTS

1. Name of first Defendant: . The first Defendant is employed as:

at . (Position and Title) (Institution)

2. Name of second Defendant: . The second Defendant is employed as:

at . (Position and Title) (Institution)

3. Name of third Defendant: . The third Defendant is employed as:

at . (Position and Title) (Institution)

4. Name of fourth Defendant: . The fourth Defendant is employed as:

at . (Position and Title) (Institution)

If you name more than four Defendants, answer the questions listed above for each additional Defendant on a separate page.

C. PREVIOUS LAWSUITS

1. Have you filed any other lawsuits while you were a prisoner? G Yes G No

2. If yes, how many lawsuits have you filed? . Describe the previous lawsuits:

a. First prior lawsuit:

1. Parties: v. 

2. Court and case number: .

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?)

.

b. Second prior lawsuit:

1. Parties: v. 

2. Court and case number: .

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?)

.

c. Third prior lawsuit:

1. Parties: v. 

2. Court and case number: .

3. Result: (Was the case dismissed? Was it appealed? Is it still pending?)

.

If you filed more than three lawsuits, answer the questions listed above for each additional lawsuit on a separate page.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 11 of 34
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D. CAUSE OF ACTION

COUNT I

1. State the constitutional or other federal civil right that was violated: 

.

2. Count I. Identify the issue involved. Check only one. State additional issues in separate counts.

G Basic necessities G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count I. Describe exactly what

each Defendant did or did not do that violated your rights. State the facts clearly in your own words without

citing legal authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

.

5. Administrative Remedies:

a. Are there any administrative remedies (grievance procedures or administrative appeals) available

at your institution? G Yes G No

b. Did you submit a request for administrative relief on Count I? G Yes G No

c. Did you appeal your request for relief on Count I to the highest level? G Yes G No

d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why

you did not. 

.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 12 of 34
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COUNT II

1. State the constitutional or other federal civil right that was violated: 

.

2. Count II. Identify the issue involved. Check only one. State additional issues in separate counts.

G Basic necessities G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count II. Describe exactly what

each Defendant did or did not do that violated your rights. State the facts clearly in your own words without

citing legal authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

.

5. Administrative Remedies.

a. Are there any administrative remedies (grievance procedures or administrative appeals) available

at your institution? G Yes G No

b. Did you submit a request for administrative relief on Count II? G Yes G No

c. Did you appeal your request for relief on Count II to the highest level? G Yes G No

d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why

you did not. 

.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 13 of 34
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COUNT III

1. State the constitutional or other federal civil right that was violated: 

.

2. Count III. Identify the issue involved. Check only one. State additional issues in separate counts.

G Basic necessities G Mail G Access to the court G Medical care 

G Disciplinary proceedings G Property G Exercise of religion G Retaliation

G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count III. Describe exactly what

each Defendant did or did not do that violated your rights. State the facts clearly in your own words without

citing legal authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

.

5. Administrative Remedies.

a. Are there any administrative remedies (grievance procedures or administrative appeals) available

at your institution? G Yes G No

b. Did you submit a request for administrative relief on Count III? G Yes G No

c. Did you appeal your request for relief on Count III to the highest level? G Yes G No

d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why

you did not. 

.

If you assert more than three Counts, answer the questions listed above for each additional Count on a separate page.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 14 of 34
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E. REQUEST FOR RELIEF

State the relief you are seeking:

.

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

Executed on 

DATE SIGNATURE OF PLAINTIFF

(Name and title of paralegal, legal assistant, or

other person who helped prepare this complaint)

(Signature of attorney, if any)

(Attorney’s address & telephone number)

ADDITIONAL PAGES

All questions must be answered concisely in the proper space on the form. If you need more space, you may

attach no more than fifteen additional pages. But the form must be completely filled in to the extent

applicable. If you attach additional pages, be sure to identify which section of the complaint is being continued

and number all pages.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 15 of 34
Revised 4/9/06

Instructions for Prisoners Applying for Leave to Proceed in Forma Pauperis

Pursuant to 28 U.S.C. § 1915 in a Civil Action (Non-habeas) in Federal Court

You must pay the full filing fee of $350.00 for a civil action. If you later file an appeal,

you will be obligated to pay the $455.00 filing fee for the appeal.

If you have enough money to pay the full filing fee, you should send a cashier’s check

or money order payable to the Clerk of the Court with your complaint, petition, or notice of

appeal.

If you do not have enough money to pay the full filing fee, you can file the action

without prepaying the filing fee. However, the court will assess an initial partial filing fee. The

initial partial filing fee will be the greater of 20% of the average monthly deposits or 20% of the

average monthly balance in your prison or jail account for the six months immediately

preceding the filing of the lawsuit. The court will order the agency that has custody of you to

withdraw the initial partial filing fee from your prison or jail account as soon as funds are

available and to forward the money to the court.

After the initial partial filing fee has been paid, you will owe the balance of the filing fee.

Until the filing fee is paid in full, each month you will owe 20% of your preceding month's

income. The agency that holds you in custody will collect that money and forward it to the

court any time the amount in your account exceeds $10.00. The balance of the filing fee may

be collected even if the action is later dismissed, summary judgment is granted against you, or

you fail to prevail at trial.

To file an action without prepaying the filing fee, and to proceed with an action in forma

pauperis, you must complete the attached form and return it to the court with your complaint.

You must have a prison or jail official complete the certificate on the bottom of the form and

attach a certified copy of your prison or jail account statement for the last six months. If you

were incarcerated in a different institution during any part of the past six months, you must

attach a certificate and a certified copy of your account statement from each institution at which

you were confined. If you submit an incomplete form or do not submit a prison or jail account

statement with the form, your request to proceed in forma pauperis will be denied.

Even if some or all of the filing fee has been paid, the court is required to dismiss your

action if: (1) your allegation of poverty is untrue; (2) the action is frivolous or malicious; (3)

your complaint does not state a claim upon which relief can be granted; or (4) your complaint

makes a claim against a defendant for money damages and that defendant is immune from

liability for money damages.

If you file more than three actions or appeals which are dismissed as frivolous or

malicious or for failure to state a claim on which relief can be granted, you will be prohibited

from filing any other action in forma pauperis unless you are in imminent danger of serious

physical injury.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 16 of 34
Revised 4/9/06 1

Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

)

 , ) CASE NO. 

Plaintiff, )

)

 vs. ) APPLICATION TO PROCEED

) IN FORMA PAUPERIS 

 , ) BY A PRISONER

Defendant(s). ) CIVIL (NON-HABEAS)

)

I, , declare, in support of my request to proceed in the above

entitled case without prepayment of fees under 28 U.S.C. § 1915, that I am unable to pay the fees for these

proceedings or to give security therefor and that I believe I am entitled to relief.

In support of this application, I answer the following questions under penalty of perjury:

1. Have you ever before brought an action or appeal in a federal court while you were incarcerated or detained?

GYes GNo If "Yes," how many have you filed? .

Were any of the actions or appeals dismissed because they were frivolous, malicious, or failed to state a

claim upon which relief may be granted? GYes GNo If "Yes," how many of them? .

2. Are you currently employed at the institution where you are confined? GYes GNo

If "Yes," state the amount of your pay and where you work. 

3. Do you receive any other payments from the institution where you are confined? GYes GNo

If "Yes," state the source and amount of the payments. 

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 17 of 34
Revised 4/9/06 2

4. Do you have any other sources of income, savings, or assets either inside or outside of the institution where

you are confined? GYes GNo

If "Yes," state the sources and amounts of the income, savings, or assets. 

I declare under penalty of perjury that the above information is true and correct.

DATE SIGNATURE OF APPLICANT

CONSENT TO COLLECTION OF FEES FROM TRUST ACCOUNT

I, , hereby consent to having the designated correctional officials at this

institution release to the Court my trust account information. I further consent to having the designated

correctional officials at this institution withdraw from my trust account the funds required to comply with the

order of this Court for the payment of filing fees in accordance with 28 U.S.C. § 1915(b).

My consent includes withdrawal from my account by correctional officials of partial initial payments to this

Court equal to 20% of the greater of:

(A) the average monthly deposits to my account for the six-month period preceding my filing of this

action, or

(B) the average monthly balance in my account for the six-month period preceding my filing of this

action.

My consent also includes monthly withdrawals from my account by correctional officials of an amount equal

to 20% of each month’s income. Whenever the amount in my account reaches $10.00, correctional officials will

withdraw that amount and forward it to the Court until the required filing fee is paid in full. I understand that I

am liable for paying the entire fee, even if my case is dismissed by the Court before the fee is fully paid.

DATE SIGNATURE OF APPLICANT

CERTIFICATE OF CORRECTIONAL OFFICIAL

AS TO STATUS OF APPLICANT’S TRUST ACCOUNT

I, , certify that as of the date applicant signed this application:

(Printed name of official)

The applicant’s trust account balance at this institution is: $

The applicant’s average monthly deposits during the prior six months is: $

The applicant’s average monthly balance during the prior six months is: $

The attached certified account statement accurately reflects the status of the applicant’s account.

DATE AUTHORIZED SIGNATURE TITLE/ID NUMBER INSTITUTION 

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 18 of 34
Revised 3/9/07 1

Instructions for Filing a Petition Under 28 U.S.C. § 2254 

for a Writ of Habeas Corpus by a Person in State Custody 

in the United States District Court for the District of Arizona

1. Who May Use This Form. To use this form, you must be a person who is currently serving

a sentence under a judgment against you in a state court. You are asking for relief from the

conviction or the sentence on the grounds that your conviction or sentence violates the United

States Constitution or other federal law. You also may use this form to challenge a state

judgment that imposed a sentence to be served in the future, but you must fill in the name of the

state where the judgment was entered. If you want to challenge a federal conviction or

sentence, you should file a motion under 28 U.S.C. § 2255 to vacate sentence in the federal

court that entered the judgment. This form should not be used in death penalty cases. If you

were sentenced to death, you are entitled to the assistance of counsel and you should request the

appointment of counsel.

2. The Form. Local Rule of Civil Procedure (LRCiv) 3.5(a) provides that habeas corpus

petitions must be filed on the court-approved form. The form must be typed or neatly

handwritten. All questions must be answered clearly and concisely in the appropriate space on

the form. If needed, you may attach additional pages. The form, however, must be completely

filled in to the extent applicable. You do not need to cite law. If you want to file a brief or

arguments, you must attach a separate memorandum. 

3. Your Signature. You must tell the truth and sign the form. If you make a false statement of

a material fact, you may be prosecuted for perjury.

4. The Filing Fee. The filing fee for this action is $5.00. If you are unable to pay the filing

fee, you may request permission to proceed in forma pauperis by completing and signing the

Application to Proceed In Forma Pauperis provided with the petition form. You must have an

official at the prison or jail complete the certificate at the bottom of the application form. If the

amount of money in your account exceeds $25.00, you must pay the $5.00 filing fee. LRCiv

3.5(b).

5. Original and Judge’s Copy. You must send an original plus one copy of your petition and

of any other document submitted to the Court. You must send one additional copy to the Court

if you wish to have a file-stamped copy of the document returned to you. All copies must be

identical to the original. Copies may be legibly handwritten.

6. Where to File. You should file your petition in the division where you were convicted. See

LRCiv 5.1(b). If you are challenging a judgment of conviction entered in Maricopa, Pinal,

Yuma, La Paz, or Gila County, file your petition in the Phoenix Division. If you are challenging

a judgment of conviction entered in Apache, Navajo, Coconino, Mohave, or Yavapai County,

file your petition in the Prescott Division. If you are challenging a judgment of conviction

entered in Pima, Cochise, Santa Cruz, Graham, or Greenlee County, file your petition in the

Tucson Division. See LRCiv 5.1(b) and 77.1(a).

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 19 of 34
2

Mail the original and one copy of your petition with the $5.00 filing fee or the

application to proceed in forma pauperis to:

Phoenix & Prescott Divisions: OR Tucson Division:

U.S. District Court Clerk U.S. District Court Clerk

U.S. Courthouse, Suite 130 U.S. Courthouse, Suite 1500

401 West Washington Street, SPC 10 405 West Congress Street

Phoenix, Arizona 85003-2119 Tucson, Arizona 85701-5010

7. Change of Address. You must immediately notify the Court and respondents in writing of

any change in your mailing address. Failure to notify the Court of any change in your mailing

address may result in the dismissal of your case.

8. Certificate of Service. You must provide the respondents with a copy of any document you

submit to the Court (except the initial petition and application to proceed in forma pauperis).

Each original document (except the initial petition and application to proceed in forma pauperis)

must include a certificate of service on the last page of the document stating the date a copy of

the document was mailed to the respondents and the address to which it was mailed. Fed. R.

Civ. P. 5(a), (d). Any document received by the Court that does not include a certificate of

service may be stricken. A certificate of service should be in the following form:

I hereby certify that a copy of the foregoing document was mailed

this (month, day, year) to:

Name: 

Address: 

 Attorney for Respondent(s)

 

(Signature)

9. Amended Petition. If you need to change any of the information in the initial petition, you

must file an amended petition. The amended petition must be written on the court-approved

form. You may file one amended petition without leave (permission) of Court before any

respondent has answered your original petition. See Fed. R. Civ. P. 15(a). After any respondent

has filed an answer, you must file a motion for leave to amend and lodge (submit) a proposed

amended petition. LRCiv 15.1. An amended petition may not incorporate by reference any part

of your prior petition. LRCiv 15.1(a)(2). Any grounds not included in the amended petition

are considered dismissed.

10. Exhibits. If available, you should attach a copy of all state and federal court written

decisions regarding the conviction you are challenging. Do not submit any other exhibits with

the petition. Instead, you should paraphrase the relevant information in the petition.

11. Letters and Motions. It is generally inappropriate to write a letter to any judge or the staff

of any judge. The only appropriate way to communicate with the Court is by filing a written

pleading or motion.

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3

12. Warnings.

a. Judgment Entered by a Single Court. You may challenge the judgment entered by

only one court. Multiple counts which resulted in a judgment by the same court may be

challenged in the same petition. If you wish to challenge judgments entered by more

than one court, however, you must file separate petitions for each judgment.

b. Grounds for Relief. You must raise all grounds for relief that relate to this conviction

or sentence. Any grounds not raised in this petition will likely be barred from being

raised in any subsequent federal action.

c. Exhaustion. In order to proceed in federal court, you ordinarily must exhaust the

remedies available to you in the state courts as to each claim on which you request action

by the federal court. If you did not fairly present each of your grounds to the Arizona

Court of Appeals, your petition may be dismissed. If you did not present one or more

of your grounds to the Arizona Court of Appeals, explain why you did not.

FINAL NOTE

You should follow these instructions carefully. Failure to do so may result in your

petition being stricken or dismissed by the Court. All questions must be answered concisely in

the proper space on the form. If you need more space, you may attach additional pages. But

the form must be completely filled in to the extent applicable. If you attach additional pages,

be sure to identify which section of the petition is being continued and number all pages.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 21 of 34
Revised 3/9/07 1 530

Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

(Failure to notify the Court of your change of address may result in dismissal of this action.) 

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

 , )

(Full Name of Petitioner) )

Petitioner, )

)

vs. ) CASE NO. 

) (To be supplied by the Clerk)

 , )

(Name of the Director of the Department of )

Corrections, Jailor or authorized person having )

custody of Petitioner) ) PETITION UNDER 28 U.S.C. § 2254

) FOR A WRIT OF HABEAS CORPUS 

Respondent, ) BY A PERSON IN STATE CUSTODY

and ) (NON-DEATH PENALTY)

The Attorney General of the State of , )

)

Additional Respondent. )

)

 PETITION

1. (a) Name and location of court that entered the judgment of conviction you are challenging: 

(b) Criminal docket or case number: 

2. Date of judgment of conviction: 

3. In this case, were you convicted on more than one count or crime? Yes G No G

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 22 of 34
2

4. Identify all counts and crimes for which you were convicted and sentenced in this case: 

5. Length of sentence for each count or crime for which you were convicted in this case: 

6. (a) What was your plea?

Not guilty G

Guilty G

Nolo contendere (no contest) G

(b) If you entered a guilty plea to one count or charge, and a not guilty plea to another count or charge,

give details: 

(c) If you went to trial, what kind of trial did you have? (Check one) Jury G Judge only G

7. Did you testify at the trial? Yes G No G

8. Did you file a direct appeal to the Arizona Court of Appeals from the judgment of conviction?

Yes G No G

If yes, answer the following:

(a) Date you filed: 

(b) Docket or case number: 

(c) Result: 

(d) Date of result: 

(e) Grounds raised: 

Attach, if available, a copy of any brief filed on your behalf and a copy of the decision by the court.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 23 of 34
3

9. Did you appeal to the Arizona Supreme Court? Yes G No G

If yes, answer the following:

(a) Date you filed: 

(b) Docket or case number: 

(c) Result: 

(d) Date of result: 

(e) Grounds raised: 

Attach, if available, a copy of any brief filed on your behalf and a copy of the decision by the court.

10. Did you file a petition for certiorari in the United States Supreme Court? Yes G No G

If yes, answer the following:

(a) Date you filed: 

(b) Docket or case number: 

(c) Result: 

(d) Date of result: 

(e) Grounds raised: 

Attach, if available, a copy of any brief filed on your behalf and a copy of the decision by the court.

11. Other than the direct appeals listed above, have you filed any other petitions, applications or motions

concerning this judgment of conviction in any state court? Yes G No G

If yes, answer the following:

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 24 of 34
4

(a) First Petition.

(1) Date you filed: 

(2) Name of court: 

(3) Nature of the proceeding (Rule 32, special action or habeas corpus): 

(4) Docket or case number: 

(5) Result: 

(6) Date of result: 

(7) Grounds raised: 

Attach, if available, a copy of any brief filed on your behalf and a copy of the decision by the court.

(b) Second Petition.

(1) Date you filed: 

(2) Name of court: 

(3) Nature of the proceeding (Rule 32, special action or habeas corpus): 

(4) Docket or case number: 

(5) Result: 

(6) Date of result: 

(7) Grounds raised: 

Attach, if available, a copy of any brief filed on your behalf and a copy of the decision by the court.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 25 of 34
5

(c) Third Petition.

(1) Date you filed: 

(2) Name of court: 

(3) Nature of the proceeding (Rule 32, special action or habeas corpus): 

(4) Docket or case number: 

(5) Result: 

(6) Date of result: 

(7) Grounds raised: 

Attach, if available, a copy of any brief filed on your behalf and a copy of the decision by the court.

(d) Did you appeal the action taken on your petition, application, or motion to the:

Arizona Court of Appeals: Arizona Supreme Court:

(1) First petition: Yes G No G Yes G No G

(2) Second petition: Yes G No G Yes G No G

(3) Third petition Yes G No G Yes G No G

(e) If you did not appeal to the Arizona Court of Appeals, explain why you did not: 

12. For this petition, state every ground on which you claim that you are being held in violation of the

Constitution, laws, or treaties of the United States. Attach additional pages if you have more than four

grounds. State the facts supporting each ground.

CAUTION: To proceed in the federal court, you must ordinarily first exhaust (use up) your available statecourt remedies on each ground on which you request action by the federal court. Also, if you fail to set

forth all the grounds in this petition, you may be barred from presenting additional grounds at a later date.

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 26 of 34
6

GROUND ONE: 

(a) Supporting FACTS (Do not argue or cite law. Just state the specific facts that support your claim.):

(b) Did you present the issue raised in Ground One to the Arizona Court of Appeals? Yes G No G

(c) If yes, did you present the issue in a: 

Direct appeal G

First petition G

Second petition G

Third petition G

(d) If you did not present the issue in Ground One to the Arizona Court of Appeals, explain why: 

(e) Did you present the issue raised in Ground One to the Arizona Supreme Court? Yes G No G

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 27 of 34
7

GROUND TWO: 

(a) Supporting FACTS (Do not argue or cite law. Just state the specific facts that support your claim.):

(b) Did you present the issue raised in Ground Two to the Arizona Court of Appeals? Yes G No G

(c) If yes, did you present the issue in a: 

Direct appeal G

First petition G

Second petition G

Third petition G

(d) If you did not present the issue in Ground Two to the Arizona Court of Appeals, explain why: 

(e) Did you present the issue raised in Ground Two to the Arizona Supreme Court? Yes G No G

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 28 of 34
8

GROUND THREE: 

(a) Supporting FACTS (Do not argue or cite law. Just state the specific facts that support your claim.):

(b) Did you present the issue raised in Ground Three to the Arizona Court of Appeals? Yes G No G

(c) If yes, did you present the issue in a: 

Direct appeal G

First petition G

Second petition G

Third petition G

(d) If you did not present the issue in Ground Three to the Arizona Court of Appeals, explain why: 

(e) Did you present the issue raised in Ground Three to the Arizona Supreme Court? Yes G No G

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 29 of 34
9

GROUND FOUR: 

(a) Supporting FACTS (Do not argue or cite law. Just state the specific facts that support your claim.):

(b) Did you present the issue raised in Ground Four to the Arizona Court of Appeals? Yes G No G

(c) If yes, did you present the issue in a: 

Direct appeal G

First petition G

Second petition G

Third petition G

(d) If you did not present the issue in Ground Four to the Arizona Court of Appeals, explain why: 

(e) Did you present the issue raised in Ground Four to the Arizona Supreme Court? Yes G No G

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 30 of 34
10

Please answer these additional questions about this petition: 

13. Have you previously filed any type of petition, application or motion in a federal court regarding the

conviction that you challenge in this petition? Yes G No G

If yes, give the date of filing, the name and location of the court, the docket or case number, the type of

proceeding, the issues raised, the date of the court’s decision, and the result for each petition, application, or

motion filed. Attach a copy of any court opinion or order, if available: 

14. Do you have any petition or appeal now pending (filed and not decided yet) in any court, either state or

federal, as to the judgment you are challenging? Yes G No G

If yes, give the date of filing, the name and location of the court, the docket or case number, the type of

proceeding, and the issues raised: 

15. Do you have any future sentence to serve after you complete the sentence imposed by the judgment you

are challenging? Yes G No G

If yes, answer the following:

(a) Name and location of the court that imposed the sentence to be served in the future:

(b) Date that the other sentence was imposed: 

(c) Length of the other sentence: 

(d) Have you filed, or do you plan to file, any petition challenging the judgment or sentence to be served

in the future? Yes G No G

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 31 of 34
11

16. TIMELINESS OF PETITION: If your judgment of conviction became final more than one year ago, you

must explain why the one-year statute of limitations in 28 U.S.C. § 2244(d) does not bar your petition.*

*Section 2244(d) provides in part that:

(1) A 1-year period of limitation shall apply to an application for a writ of habeas corpus by a person

in custody pursuant to the judgment of a State court. The limitation period shall run from the latest of-

(A) the date on which the judgment became final by the conclusion of direct review or the

expiration of the time for seeking such review;

(B) the date on which the impediment to filing an application created by State action in

violation of the Constitution or laws of the United States is removed, if the applicant was

prevented from filing by such State action;

(C) the date on which the constitutional right asserted was initially recognized by the Supreme

Court, if the right has been newly recognized by the Supreme Court and made retroactively

applicable to cases on collateral review; or

(D) the date on which the factual predicate of the claim or claims presented could have been

discovered through the exercise of due diligence.

(2) The time during which a properly filed application for State post-conviction or other collateral

review with respect to the pertinent judgment or claim is pending shall not be counted toward any

period of limitation under this subsection.

17. Petitioner asks that the Court grant the following relief: 

or any other relief to which Petitioner may be entitled. (Money damages are not available in habeas corpus

cases.)

I declare under penalty of perjury that the foregoing is true and correct and that this Petition for Writ of

Habeas Corpus was placed in the prison mailing system on (month, day, year).

Signature of Petitioner

Signature of attorney, if any Date

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 32 of 34
98-ifphab

Revised 6/98 1

Name and Prisoner/Booking Number

Place of Confinement

Mailing Address

City, State, Zip Code

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

)

 , )

Petitioner, ) CASE NO. 

)

 vs. )

) APPLICATION TO PROCEED

 , ) IN FORMA PAUPERIS

Respondent(s). ) BY A PRISONER

) (HABEAS)

I, , declare, in support of my request to proceed in the above

entitled case without prepayment of fees under 28 U.S.C. § 1915, that I am unable to pay the fees for these

proceedings or to give security therefor and that I believe I am entitled to relief.

In support of this application, I answer the following questions under penalty of perjury:

1. Are you currently employed at the institution where you are confined? GYes GNo

If "Yes," state the amount of your pay and where you work. 

2. Do you receive any other payments from the institution where you are confined? GYes GNo

If "Yes," state the source and amount of the payments. 

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 33 of 34
2

3. Do you have any other sources of income, savings, or assets either inside or outside of the institution where

you are confined? GYes GNo

If "Yes," state the sources and amounts of the income, savings, or assets. 

I declare under penalty of perjury that the above information is true and correct.

DATE SIGNATURE OF APPLICANT

CERTIFICATE OF CORRECTIONAL OFFICIAL

AS TO STATUS OF APPLICANT’S TRUST ACCOUNT

I, , certify that as of the date applicant signed this application:

(Printed name of official)

The applicant’s trust account balance at this institution is: $ .

DATE AUTHORIZED SIGNATURE TITLE/ID NUMBER INSTITUTION 

Case 2:08-cv-02361-DGC--LOA Document 6 Filed 02/05/09 Page 34 of 34