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KM 

WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Gary Jerome Harper, et al., 

Plaintiffs, 

v. 

Jim McCabe, et al., 

Defendants. 

No. CV 15-08208-PCT-DGC (DKD) 

ORDER 

Plaintiff Gary Jerome Harper, who is confined in the Mohave County Jail, and 

Plaintiffs Cathy Jones, Steve Ayers, Cameo Austin-Blake, Carrissa Bobak, Bobby Bobak, 

Jackie Doughtery, Eric Perez, Annette Murphy, Robert Vogt, Nicholas McCoy, Steven 

Foster, Jeffry Dial, Geoff Burbak, Jeff Sevick, Chad Puett, Tyler Beeding, Ryan 

O’Sullivan, Michelle Burns, Ronald Maher, and David Watkins have filed a pro se civil 

rights Complaint pursuant to 42 U.S.C. § 1983. Plaintiff Harper has also filed an 

incomplete Application to Proceed In Forma Pauperis (Doc. 2). The Court will dismiss 

all Plaintiffs except Plaintiff Harper. The Court will also dismiss the Complaint with 

leave to amend and deny the deficient Application to Proceed. Plaintiff Harper will have 

30 days to pay the filing and administrative fees or file a complete Application to Proceed 

In Forma Pauperis, and file an amended complaint on the court-approved form. 

I. Dismissal of Plaintiffs 

Generally, plaintiffs may join in one action if they assert any right to relief arising 

out of the same occurrence or series of occurrences and if any question of law or fact in 

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common to all plaintiffs will arise in the action. Fed. R. Civ. P. 20. Rule 21 of the 

Federal Rules of Civil Procedure, however, authorizes the Court to drop parties on just 

terms and sever claims. See Desert Empire Bank v. Ins. Co. of N. Am., 623 F.2d 1371, 

1375 (9th Cir. 1980) (even if the specific requirements of Rule 20 may be satisfied, a trial 

court must examine other relevant factors to determine if joinder of a party will comport 

with principles of fundamental fairness). 

Even if Plaintiffs in this action are properly joined, the Court has found that 

management of pro se multi-plaintiff inmate litigation presents significant burdens to 

both the parties and the Court. Plaintiffs are inmates proceeding pro se, and, although 

each Plaintiff may appear on his own behalf, none may appear as an attorney for the 

others. Johns v. County of San Diego, 114 F.3d 874, 877 (9th Cir. 1997). Therefore, 

during the prosecution of this action, each Plaintiff would be required to sign and submit 

his own motions and notices related to his claims in the action, and all Plaintiffs would be 

required to individually sign any motion or notice filed on behalf of all Plaintiffs. 

Because of security concerns related to inmate correspondence and face-to-face 

communications, Plaintiffs would have at best only a very limited opportunity to discuss 

case strategy, share discovery, or even provide each other copies of the motions and 

notices they file with the Court. Joint prosecution of the lawsuit by multiple inmates 

would be limited, if not virtually impossible, due to the regulation of inmate-to-inmate 

correspondence. Moreover, inmates are subject to transfer at any time to a facility other 

than the one they are incarcerated in at the time of the lawsuit and it is unclear, in this 

case, if each of the named Plaintiffs is presently incarcerated. 

With these concerns in mind, the Court concludes that unitary adjudication of 

Plaintiffs’ claims would result in unfairness to Plaintiffs, Defendants, and the Court’s 

goals of achieving judicial economy and maintaining efficient control of the Court’s 

docket. Allowing each Plaintiff to proceed separately will overcome the unfairness 

created by these circumstances. The Court notes that only Plaintiff Harper signed the 

Complaint and Application to Proceed. Accordingly, the Court will dismiss Plaintiffs 

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Jones, Ayers, Austin-Blake, Carrissa Bobak, Bobby Bobak, Doughtery, Perez, Murphy, 

Vogt, McCoy, Foster, Dial, Burbank, Sevick, Puett, Beeding, O’Sullivan, Burns, Maher, 

and Watkins. Plaintiff Harper may litigate this action on his own behalf. The dismissed 

Plaintiffs must proceed individually by filing new actions on their own behalf. 

II. 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).

III. Application Fails to Comply With Statute

 Plaintiff Harper has used the court-approved form, but he has not submitted a 

certified six-month trust account statement. In light of this deficiency, the Court will 

deny the Application to Proceed and will give Plaintiff Harper 30 days to either pay the 

$400.00 filing and administrative fees or file a complete Application to Proceed In Forma 

Pauperis and certified six-month trust account statement. 

/ / / 

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IV. Failure to File on Form 

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

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.” The Complaint is not filed on the court-approved 

form. The Court will therefore dismiss the Complaint without prejudice, with leave to 

amend. Within 30 days, Plaintiff Harper may submit an amended complaint on a courtapproved form, on his own behalf. The Clerk of Court will mail Plaintiff Harper a courtapproved form to use for filing an amended complaint. If Plaintiff Harper fails to use the 

court-approved form, the Court may strike the amended complaint and dismiss the case 

without further notice to Plaintiff. 

 Plaintiff Harper 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. 

 For each count, Plaintiff Harper must write short, plain statements telling the 

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

Plaintiff’s constitutional right; and (5) what specific injury that Plaintiff suffered because 

of that Defendant’s conduct. Rizzo v. Goode, 423 U.S. 362, 371-72, 377 (1976). 

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

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

the specific injury suffered by Plaintiff, the allegation 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. 

 A first amended complaint supersedes the original complaint. Ferdik v. Bonzelet, 

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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 an original 

complaint as nonexistent. 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 a first amended complaint. Lacey v. Maricopa 

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

V. Warnings

A. Release

 If Plaintiff Harper is released while this case remains pending, and the filing fee 

has not been paid in full, Plaintiff must, within 30 days of his release, either (1) notify the 

Court that he intends to pay the unpaid balance of his filing fee within 120 days of his 

release or (2) file a non-prisoner application to proceed in forma pauperis. Failure to 

comply may result in dismissal of this action. 

B. Address Changes

 Plaintiff Harper 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. 

C. Copies

 Plaintiff Harper 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. 

 D. Possible Dismissal 

 If Plaintiff Harper 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). 

. . . . 

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IT IS ORDERED:

 (1) Plaintiffs Jones, Ayers, Austin-Blake, Carrissa Bobak, Bobby Bobak, 

Doughtery, Perez, Murphy, Vogt, McCoy, Foster, Dial, Burbank, Sevick, Puett, Beeding, 

O’Sullivan, Burns, Maher, and Watkins are dismissed from this action. Plaintiff Harper 

must proceed only on his own behalf. 

 (2) Plaintiff Harper’s Application to Proceed In Forma Pauperis (Doc. 2) is 

denied without prejudice. 

 (3) Within 30 days of the date this Order is filed, Plaintiff Harper 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. 

 (4) If Plaintiff Harper 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. 

 (5) The Clerk of the Court must mail Plaintiff Harper a court-approved form 

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

 (6) The Complaint (Doc. 1) is dismissed without prejudice for failure to 

comply with Local Rule of Civil Procedure 3.4. Plaintiff Harper has 30 days from the 

date this Order is filed to file an amended complaint in compliance with this Order. 

 (7) If a Plaintiff Harper fails to file an amended complaint within 30 days, the 

Clerk of Court must, without further notice, enter a judgment of dismissal of that 

Plaintiff’s case action without prejudice and without further notice to that Plaintiff. 

. . . . 

. . . . 

. . . . 

. . . . 

. . . . 

. . . . 

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 (8) The Clerk of Court must mail each Plaintiff a court-approved form for 

filing a civil rights complaint by a prisoner and a court-approved form for filing an 

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

 Dated this 26th day of October, 2015. 

Case 3:15-cv-08208-DGC--DKD Document 4 Filed 10/26/15 Page 7 of 20
Revised 5/1/2013 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.

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:

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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 court-approved

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.

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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.

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Revised 5/1/2013 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: .

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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:

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.

Case 3:15-cv-08208-DGC--DKD Document 4 Filed 10/26/15 Page 16 of 20
6

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 3:15-cv-08208-DGC--DKD Document 4 Filed 10/26/15 Page 17 of 20
Revised 5/1/2013

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 $455.00 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. 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 3:15-cv-08208-DGC--DKD Document 4 Filed 10/26/15 Page 18 of 20
Revised 5/1/2013 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 3:15-cv-08208-DGC--DKD Document 4 Filed 10/26/15 Page 19 of 20
Revised 5/1/2013 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 3:15-cv-08208-DGC--DKD Document 4 Filed 10/26/15 Page 20 of 20