Shuffler v. Arizona, State of et al

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KEB
WO
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
Jacob Raymond Douglas Shuffler, by
and through Next Friend Gregory Lee
Cook,
Plaintiff,
v.
State of Arizona, et al.,
Defendants.
No. CV-25-08238-PCT-JAT (MTM)
ORDER
On November 7, 2025, Gregory Lee Cook filed a pro se civil rights Complaint
pursuant to 42 U.S.C. § 1983 (Doc. 1) and paid the filing fee as the purported “next friend”
of Plaintiff Jacob Raymond Douglas Shuffler, who is incarcerated in the Mohave County
Jail in Kingman, Arizona.1 The Court will deny Mr. Cook’s “next friend” status and
dismiss the Complaint and this action without prejudice.
Under Article III of the United States Constitution, a federal court cannot consider
the merits of a legal claim unless the person seeking to invoke the jurisdiction of the court
establishes the requisite standing to sue. Whitmore v. Arkansas, 495 U.S. 149, 154 (1990).
A litigant demonstrates standing by showing that he or she has suffered an injury in fact
that is fairly traceable to the challenged action and is redressable by a favorable judicial
decision. Steel Co. v. Citizens for a Better Env’t, 523 U.S. 83, 103 (1998). Mr. Cook has
1 https://www.mohave.gov/departments/sheriff/press-release.
[https://perma.cc/6E5K-LS4U].
Case 3:25-cv-08238-JAT--MTM Document 4 Filed 01/12/26 Page 1 of 16

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no standing on his own in this action.
However, “next friend” standing “has long been an accepted basis for jurisdiction
in certain circumstances.” Whitmore, 495 U.S. at 162. “Most frequently, ‘next friends’
appear in court on behalf of detained prisoners who are unable, usually because of mental
incompetence or inaccessibility, to seek relief themselves.” Id.
“‘[N]ext friend’ standing is by no means granted automatically to whomever seeks
to pursue an action on behalf of another.” Id. To qualify for “next friend” standing, a “next
friend” must “provide an adequate explanation—such as inaccessibility, mental
incompetence, or other disability—why the real party in interest cannot appear on his own
behalf to prosecute the action,” must be “truly dedicated to the best interests of the person
on whose behalf he seeks to litigate,” and “must have some significant relationship with
the real party in interest.” Id. at 163–64. “The burden is on the ‘next friend’ clearly to
establish the propriety of his status and thereby justify the jurisdiction of the court.” Id.
at 164.
Mr. Cook does not provide an adequate explanation why Plaintiff cannot appear on
his own to prosecute this civil rights action and has not otherwise shown he is entitled to
next friend status. Accordingly, Mr. Cook does not have standing to proceed as “next
friend” of Plaintiff, and the Court will dismiss the Complaint and this action for lack of
jurisdiction.
If Plaintiff wants to file a civil rights complaint pursuant to 42 U.S.C. § 1983, he
must file his complaint on a court-approved form in a new action, accompanied by either
the statutory filing fee or an Application to Proceed In Forma Pauperis. As a courtesy, the
Court will direct the Clerk of Court to send Plaintiff this Court’s approved forms for filing
a civil rights complaint and an Application to Proceed In Forma Pauperis. Plaintiff may
not, however, file those documents in this action; he must file a new action.
IT IS ORDERED:
(1) Gregory Lee Cook’s next friend standing is denied.
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(2) The Complaint (Doc. 1) and this action are dismissed without prejudice,
and the Clerk of Court must enter judgment accordingly.
(3) The Clerk of Court must send Gregory Lee Cook a copy of this Order at
11056 E. Calle Gila, Kingman, AZ 86401.
(4) The Clerk of Court must mail Plaintiff the current court-approved forms for
filing a civil rights complaint by a prisoner and an Application to Proceed In Forma
Pauperis (Non-Habeas) at the following address: Mohave County Jail, 501 W. Historic Rte.
66, Kingman, AZ 86401.
Dated this 12th day of January, 2026.
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Revised 11/6/24
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 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 $405.00 ($350.00 filing
fee plus $55.00 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. 	Unless you are an inmate housed at an Arizona Department of Corrections facility
that participates in electronic filing, mail the original and one copy of the complaint with the
$405 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. 	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.
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Revised 12/1/23 	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.
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Revised 12/1/23
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 $55.00 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 $405.00 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 $405.00 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 $55.00 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.
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Revised 12/1/23
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___________________________________________
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 12/1/23
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 3:25-cv-08238-JAT--MTM Document 4 Filed 01/12/26 Page 16 of 16