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NA 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

James Strouse, 

Plaintiff, 

v. 

Unknown Madrid, et al., 

Defendants. 

No. CV 18-00111-TUC-RCC 

ORDER 

On September 21, 2017, Plaintiff James Strouse (hereafter, “Plaintiff”) and five 

other inmates, who were apparently all confined in the United States PenitentiaryTucson, filed a pro se civil rights Complaint pursuant to Bivens v. Six Unknown Named 

Agents of Federal Bureau of Narcotics, 403 U.S. 388 (1971). See Strouse v. Madrid, CV 

17-00471-TUC-RCC, Doc. 1. Plaintiff also filed a Motion to Proceed In Forma Pauperis. 

Id., Doc. 2. In a February 28, 2018 Order, the Court dismissed the action and directed the 

Clerk of Court to open new, separate actions on behalf of each of the plaintiffs. Id., Doc. 

36. The Court ordered that a copy of the Complaint and its Order be filed in each new 

case and that a copy of Plaintiff’s Motion to Proceed In Forma Pauperis be filed in the 

new case opened for him. The Clerk of Court did so. 

This action is assigned to Plaintiff, who is now confined in the United States 

Penitentiary-Coleman II in Coleman, Florida. Plaintiff’s Complaint and Motion to 

Proceed have been filed in this new action as Documents 2 and 3, respectively. The 

Court will deny the deficient Motion to Proceed and dismiss the Complaint with leave to 

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amend. The Court will give Plaintiff 30 days to (1) file an amended complaint and (2) 

either pay the filing and administrative fees or file a complete Application to Proceed In 

Forma Pauperis. 

I. Payment of Filing Fee 

 When bringing an action, a prisoner must either pay the $350.00 filing fee and a 

$50.00 administrative fee in a lump sum or, if granted the privilege of proceeding in 

forma pauperis, pay the $350.00 filing fee incrementally as set forth in 28 U.S.C. 

§ 1915(b)(1). An application to proceed in forma pauperis requires an affidavit of 

indigence and a certified copy of the inmate’s trust account statement for the six months 

preceding the filing of the Complaint. 28 U.S.C. § 1915(a)(2). An inmate must submit 

statements from each institution where the inmate was confined during the six-month 

period. Id. To assist prisoners in meeting these requirements, the Court requires use of a 

form application. LRCiv 3.4. 

 If a prisoner is granted leave to proceed in forma pauperis, the Court will assess an 

initial partial filing fee of 20% of either the average monthly deposits or the average 

monthly balance in Plaintiff’s account, whichever is greater. 28 U.S.C. § 1915(b)(1). An 

initial partial filing fee will only be collected when funds exist. 28 U.S.C. § 1915(b)(4). 

The balance of the $350.00 filing fee will be collected in monthly payments of 20% of 

the preceding month’s income credited to an inmate’s account, each time the amount in 

the account exceeds $10.00. 28 U.S.C. § 1915(b)(2).

II. Motion to Proceed In Forma Pauperis 

 Plaintiff has failed to use the court-approved form, and he has not submitted a 

certified six-month trust account statement. In light of these deficiencies, the Court will 

deny the Motion to Proceed and will give Plaintiff 30 days to either pay the $400.00 

filing and administrative fees or file a complete Application to Proceed In Forma 

Pauperis. 

III. Complaint Not on Court-Approved Form

 Local Rule of Civil Procedure 3.4 requires in part that “[a]ll complaints and 

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applications to proceed in forma pauperis by incarcerated persons shall be signed and 

legibly written or typewritten on forms approved by the Court and in accordance with the 

instructions provided with the forms.” Plaintiff’s Complaint is not on a court-approved 

form as required by Local Rule of Civil Procedure 3.4. While the Court may, in its 

discretion, forgo the requirement that a plaintiff use a court-approved form, it declines to 

do so here because it is difficult to determine how many claims Plaintiff is asserting, and, 

because the Complaint was originally filed with other inmates, some of the claims lack 

specific factual information regarding how Plaintiff was injured by alleged constitutional 

violations. The Complaint will therefore be dismissed without prejudice, with leave to 

amend, so that Plaintiff may file an amended complaint using the court-approved form. 

 Within 30 days, Plaintiff may submit a first amended complaint on a courtapproved form. The Clerk of Court will mail Plaintiff a court-approved form to use for 

filing a first amended complaint. If Plaintiff fails to use the court-approved form, the 

Court may strike the amended complaint and dismiss this action without further notice to 

Plaintiff. 

 Plaintiff must clearly designate on the face of the document that it is the “First 

Amended Complaint.” The first amended complaint must be retyped or rewritten in its 

entirety on the court-approved form and may not incorporate any part of the original 

Complaint by reference. Plaintiff may include only one claim per count. 

 If Plaintiff files an amended complaint, Plaintiff must write short, plain statements 

telling the Court: (1) the constitutional right Plaintiff believes was violated; (2) the 

name of the Defendant who violated the right; (3) exactly what that Defendant did 

or failed to do; (4) how the action or inaction of that Defendant is connected to the 

violation of Plaintiff’s constitutional right; and (5) what specific injury Plaintiff 

suffered because of that Defendant’s conduct. See Rizzo v. Goode, 423 U.S. 362, 371-

72, 377 (1976). 

 Plaintiff must repeat this process for each person he names as a Defendant. If 

Plaintiff fails to affirmatively link the conduct of each named Defendant with the specific 

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injury suffered by Plaintiff, the allegations against that Defendant will be dismissed for 

failure to state a claim. Conclusory allegations that a Defendant or group of 

Defendants has violated a constitutional right are not acceptable and will be 

dismissed.

 Any amended complaint will supersede Plaintiff’s original Complaint. See Ferdik 

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

Co., 896 F.2d 1542, 1546 (9th Cir. 1990). After amendment, the Court will treat the 

original Complaint as nonexistent. See Ferdik, 963 F.2d at 1262. Any cause of action 

that was raised in the original complaint and that was voluntarily dismissed or was 

dismissed without prejudice is waived if it is not alleged in an amended complaint. Lacey 

v. Maricopa County, 693 F.3d 896, 928 (9th Cir. 2012) (en banc). 

IV. 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. 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). 

IT IS ORDERED:

 (1) Plaintiff’s Motion to Proceed In Forma Pauperis (Doc. 3) is denied without 

prejudice. 

 (2) Within 30 days of the date this Order is filed, Plaintiff must either pay the 

$350.00 filing fee and $50.00 administrative fee or file a complete Application to 

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

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 (3) If Plaintiff fails to either pay the $350.00 filing fee and $50.00 

administrative fee or file a 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 and deny any pending unrelated motions 

as moot. 

(4) The Complaint (Doc. 2) is dismissed without prejudice for failure to file on 

the court-approved form. Plaintiff has 30 days from the date this Order is filed to file a 

first amended complaint in compliance with this Order. 

 (5) If Plaintiff fails to file an amended complaint within 30 days, the Clerk of 

Court must, without further notice, enter a judgment of dismissal of this action without 

prejudice. 

(6) The Clerk of Court must mail Plaintiff the court-approved forms for filing 

an Application to Proceed In Forma Pauperis (Non-Habeas) and a civil rights complaint 

by a prisoner. 

 Dated this 12th day of April, 2018. 

Case 4:18-cv-00111-RCC-PSOT Document 5 Filed 04/13/18 Page 5 of 18
Revised 3/11/16 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 and Administrative Fees. The total fees for this action are $400.00 ($350.00 filing 

fee plus $50.00 administrative fee). If you are unable to immediately pay the fees, 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. This section does not apply to 

inmates housed at an Arizona Department of Corrections facility that participates in 

electronic filing.

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 $400 filing and 

administrative fees or the application to proceed in forma pauperis to:

Case 4:18-cv-00111-RCC-PSOT Document 5 Filed 04/13/18 Page 6 of 18
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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. This section does not apply to inmates housed at an Arizona Department of 

Corrections facility that participates in electronic filing.

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 

court-approved civil rights complaint form. You may file one amended complaint without leave 

(permission) of Court within 21 days after serving it or within 21 days after any defendant has filed 

an answer, whichever is earlier. See Fed. R. Civ. P. 15(a). Thereafter, 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.

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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.

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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 4:18-cv-00111-RCC-PSOT Document 5 Filed 04/13/18 Page 9 of 18
Revised 3/11/16 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,

v. 

(1) _______________________________________ , (Full Name of Defendant)

(2) _______________________________________ ,

(3) _______________________________________ ,

(4) _______________________________________ ,

Defendant(s).

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

CASE NO. __________________________________ 

(To be supplied by the Clerk)

CIVIL RIGHTS COMPLAINT

BY A PRISONER

G Original Complaint

G First Amended Complaint

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: .

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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:

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.

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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. 

.

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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. 

.

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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.

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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 4:18-cv-00111-RCC-PSOT Document 5 Filed 04/13/18 Page 15 of 18
Revised 3/15/2016 

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 $350.00 filing fee plus the $50.00 administrative fees for a civil action. If you 

later file an appeal, you will be obligated to pay the $505.00 filing fee for the appeal. 

If you have enough money to pay the full $400.00 filing and administrative fees, you should send a 

cashier=s check or money order payable to the Clerk of the Court with your complaint. 

If you do not have enough money to pay the full $400.00 filing and administrative fees, you can 

file the action without prepaying the fees. 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 $350.00 filing fee 

(you will not be required to pay the $50.00 administrative 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. 

These installment fees are calculated on a per-case basis. This means that you will be required to pay 

20% of your preceding month=s income for each civil non-habeas corpus case in which you have an 

outstanding filing fee balance. For example, if you are making payments toward filing fee balances in 

two civil non-habeas corpus cases, 40% of your preceding month=s income will be collected each month. 

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 4:18-cv-00111-RCC-PSOT Document 5 Filed 04/13/18 Page 16 of 18
Revised 6/22/16 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

 _____________________________________ , 

Plaintiff, 

v. 

 _____________________________________ , 

Defendant(s). 

CASE NO. __________________________________ 

APPLICATION TO PROCEED 

IN FORMA PAUPERIS 

BY A PRISONER 

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 4:18-cv-00111-RCC-PSOT Document 5 Filed 04/13/18 Page 17 of 18
Revised 6/22/16 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 

 ACKNOWLEDGEMENT OF COLLECTION OF FILING FEES FROM TRUST ACCOUNT 

I, , acknowledge that upon granting this Application, the Court 

will order designated correctional officials at this institution, or any other correctional institution to which I am 

transferred, to withdraw money from my trust account for payment of the filing fee, as required by 28 U.S.C. 

§ 1915(b). 

 The Court will require correctional officials to withdraw an initial partial payment 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. 

 After the initial payment, if the amount in my account is at least $10.00, the Court will require correctional 

officials to withdraw from my account 20% of each month’s income and forward it to the Court until the required 

filing fee is paid in full. I understand that I am required to pay the entire fee, even if my case is dismissed by the 

Court before the fee is fully paid. 

 I further understand that if I file more than one action, correctional officials will be ordered to withdraw 20% 

of each month’s income, for each action, simultaneously. Accordingly, if I have filed two actions, correctional 

officials will withdraw 40% of my income each month; three actions will require 60% of my income each month, 

etc. 

________________________________ ____________________________________________ 

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 4:18-cv-00111-RCC-PSOT Document 5 Filed 04/13/18 Page 18 of 18