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MH 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Jorge A. Ortiz-Feliciano, 

Plaintiff, 

v. 

J.T. Shartle, et al., 

Defendants. 

No. CV 18-00136-TUC-CKJ 

ORDER 

On March 12, 2018, Plaintiff Jorge A. Ortiz-Feliciano, who is confined in the 

United States Penitentiary-Tucson, 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) and an Application to Proceed In Forma Pauperis. On March 22, 2018, he filed a 

Motion for Appointment of Counsel.1

 In a March 26, 2018 Order, the Court denied the 

Application to Proceed as deficient and gave Plaintiff 30 days to either pay the filing and 

administrative fees or file a complete Application to Proceed In Forma Pauperis. On 

April 26, 2018, Plaintiff submitted a $5.00 payment. 

I. Payment of Filing Fee 

 As the Court explained in its March 26, 2018 Order, a prisoner bringing a civil 

action must either pay the $400.00 filing and administrative fees in a lump sum or, if 

 

1

 Because this Motion was docketed the same day the Court’s March 26, 2018 Order was signed, the Court did not have an opportunity to address Plaintiff’s Motion for Appointment of Counsel. In any event, the Court will defer ruling on the Motion for Appointment of Counsel until after Plaintiff has complied with the filing fee requirements as set forth herein. 

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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). Thus, Plaintiff cannot proceed in 

this action unless he either (1) pays the remainder of the fees ($395.00) in a lump sum or

(2) submits a complete Application to Proceed In Forma Pauperis using the form attached 

to this Order.2

 Accordingly, Plaintiff will have 30 days from the filing date of this Order 

to pay the remaining fee balance or submit a properly executed Application to Proceed In 

Forma Pauperis that includes a certified six-month trust account statement. 

II. 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 v. 

Bonzelet, 963 F.2d 1258, 1260-61 (9th Cir. 1992) (a district court may dismiss an action 

for failure to comply with any order of the Court). 

IT IS ORDERED:

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

$395.00 filing and administrative fee balance or file a complete Application to Proceed 

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

 (2) 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 

 

2

 If Plaintiff is granted in forma pauperis status, his April 26, 2018 payment will be applied toward his filing fee balance. 

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prejudice and without further notice to Plaintiff and deny any pending unrelated motions 

as moot. 

 (3) The Clerk of Court must mail Plaintiff a court-approved form for filing an 

Application to Proceed In Forma Pauperis (Non-Habeas). 

 Dated this 2nd day of May, 2018. 

Case 4:18-cv-00136-CKJ-PSOT Document 8 Filed 05/04/18 Page 3 of 6
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-00136-CKJ-PSOT Document 8 Filed 05/04/18 Page 4 of 6
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. 

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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 

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