Arellano v. Rivas

OCR transcription for search; preserved printed pages are authoritative

Case 2:25-cv-02827-JAT--ASB Document5 Filed 01/08/26 Page1of18

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6 IN THE UNITED STATES DISTRICT COURT

7 FOR THE DISTRICT OF ARIZONA

8

9) Israel Nava Arellano, No. CV-25-02827-PHX-JAT (ASB)
10 Plaintiff,
11) vy. ORDER
12| David R. Rivas,
13 Defendant.
14
15 Self-represented Plaintiff Israel Nava Arellano, who is confined in the San Luis
16| Regional Detention Center, has filed a “Petition to Grant Postage Fees for Court
17| Proceedings,” which the Clerk of Court filed as a prisoner civil rights complaint under 42
18| U.S.C. § 1984 to facilitate the Court’s consideration of it. (Doc. 1). Plaintiff also filed an
19| Application to Proceed In Forma Pauperis (Doc. 2). The Court will construe the Petition
20| asaMotion forInjunctive Relief, deny the Motion and Application to Proceed, and dismiss
21 | this case.
22 In his Motion, Plaintiff claims his Petition was retumed to him and the officer in
23 charge informed him that her department could not cover the mailing fees to send
24| Plaintiff's voluminous Petition to the Court. Plaintiff asks the Court to order the Warden
25| of San Luis Regional Detention Center and his officials to “no[t] interrupt or obstruct
26 | [Plaintiffs] court proceedings.” (Doc. 1.)
27 Motions forinjunctive relief are not independent actions but, rather, a means to seek
28 extraordinary relief in an ongoing action that has been initiated by filing a complaint or

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other proper petition that alleges jurisdictional facts. Indeed, Rule 65 of the Federal Rules
of Civil Procedure, which provides for the granting of preliminary injunctions and
temporary restraining orders, “was designed solely as a procedural tool to expedite the
action and accommodate the court and the litigants” and “does not confer either subject
matter or personal jurisdiction on the court.” Citizens Concerned for the Separation of
Church and State v. City and County of Denver, 628 F.2d 1289, 1299 (10th Cir. 1980).
Before seeking injunctive relief, Plaintiff must first have a Complaint pending before the
Court. See Stewart v. United States Immigration & Naturalization Serv., 762 F.2d 193,
198 (2d Cir. 1985) (“Only after an action has been commenced can preliminary injunctive
relief be obtained.”); see also Devose v. Herrington, 42 F.3d 470, 471 (8th Cir. 1994) (per
curiam) (a party seeking injunctive relief must establish a relationship between the claimed
injury and the conduct asserted in the complaint). Because there is no Complaint pending
before the Court, Plaintiff’s Motion to Grant Postage Fees for Court Proceedings is not
properly before the Court. Accordingly, the Court will deny the Motion and dismiss this
case.
Plaintiff may file a motion for a preliminary injunction in a new case, so long as
Plaintiff first files, in the new case, a signed civil rights complaint on a court-approved
form and either pays the filing and administrative fees or files an Application to Proceed
In Forma Pauperis. As a courtesy, the Court will direct the Clerk of Court to provide
Plaintiff with the court-approved forms for filing a civil rights Complaint and an
Application to Proceed In Forma Pauperis.
IT IS ORDERED:
(1) Plaintiff’s “Petition to Grant Postage Fees for Court Proceedings” (Doc. 1)
is denied without prejudice.
(2) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 2) is denied
without prejudice.
(3) The Clerk of Court must close this case.
Case 2:25-cv-02827-JAT--ASB Document 5 Filed 01/08/26 Page 2 of 18

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(4) The Clerk of Court must mail 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 District Court Without Prepaying Fees and Costs.
Dated this 8th day of January, 2026.
Case 2:25-cv-02827-JAT--ASB Document 5 Filed 01/08/26 Page 3 of 18

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:
Case 2:25-cv-02827-JAT--ASB Document 5 Filed 01/08/26 Page 4 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.
Case 2:25-cv-02827-JAT--ASB Document 5 Filed 01/08/26 Page 5 of 18

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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 2:25-cv-02827-JAT--ASB Document 5 Filed 01/08/26 Page 7 of 18

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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Case 2:25-cv-02827-JAT -- ASB
Document 5 Filed 01/08/26 Page 14 of 18
Page 1 of 5
AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
UNITED STATES DISTRICT COURT for the
Plaintiff/Petitioner V.
Defendant/Respondent
) ) ) ) )
Civil Action No.
APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Long Form)
Affidavit in Support of the Application
Instructions
Complete all questions in this application and then sign it. Do not leave any blanks: if the answer to a question is "0," "none," or "not applicable (N/A)," write that response. If you need more space to answer a question or to explain your answer, attach a separate sheet of paper identified with your name, your case's docket number, and the question number.
Date:
1. For both you and your spouse estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise.
Income source
Average monthly income amount during the past 12 months
Income amount expected next month
You
Spouse
You
Spouse
Employment
$
$
$
$
Self-employment
$
$
$
$
Income from real property (such as rental income)
$
$
$
$
Interest and dividends
$
$
$
$
Gifts
$
$
$
$
Alimony
$
$
$
$
Child support
$
$
$
$
I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief requested. I declare under penalty of perjury that the information below is true and understand that a false statement may result in a dismissal of my claims.
Signed:

Page 2 of 5
AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
Retirement (such as social security, pensions, annuities,
insurance) $ 	$ 	$ 	$
Disability (such as social security, insurance payments) $ 	$ 	$ 	$
Unemployment payments $ 	$ 	$ 	$
Public-assistance (such as welfare) $ 	$ 	$ 	$
Other (specify): $ 	$ 	$ 	$
Total monthly income: $ 	$ 	$ 	$
2. 	List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or
other deductions.)
Employer 	Address 	Dates of employment 	Gross
monthly pay
$
$
3. 	List your spouse's employment history for the past two years, most recent employer first. (Gross monthly pay is before
taxes or other deductions.)
Employer 	Address 	Dates of employment 	Gross
monthly pay
$
$
$
4. 	How much cash do you and your spouse have? $
Below, state any money you or your spouse have in bank accounts or in any other financial institution.
Financial institution 	Type of account 	Amount you have 	Amount your
spouse has
$ 	$
$ 	$
$ 	$
If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts,
expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts,
perhaps because you have been in multiple institutions, attach one certified statement of each account.
0.00	0.00	0.00	0.00
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Page 3 of 5
AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
5. 	List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary
household furnishings.
Assets owned by you or your spouse
Home (Value) 	$
Other real estate (Value) $
Motor vehicle #1 (Value) 	$
Make and year:
Model:
Registration #:
Motor vehicle #2 (Value) 	$
Make and year:
Model:
Registration #:
Other assets (Value) 	$
Other assets (Value) 	$
6. 	State every person, business, or organization owing you or your spouse money, and the amount owed.
Person owing you or your spouse
money
Amount owed to you 	Amount owed to your spouse
$ 	$
$ 	$
$ 	$
7. 	State the persons who rely on you or your spouse for support.
Name (or, if under 18, initials only) 	Relationship 	Age
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Page 4 of 5
AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
8. 	Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your
spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the
monthly rate.
You 	Your spouse
Rent or home-mortgage payment (including lot rented for mobile home)
$ 	$	Are real estate taxes included? 	’ Yes 	’ No
Is property insurance included? ’ Yes 	’ No
Utilities (electricity, heating fuel, water, sewer, and telephone) 	$ 	$
Home maintenance (repairs and upkeep) 	$ 	$
Food 	$ 	$
Clothing 	$ 	$
Laundry and dry-cleaning 	$ 	$
Medical and dental expenses 	$ 	$
Transportation (not including motor vehicle payments) 	$ 	$
Recreation, entertainment, newspapers, magazines, etc. 	$ 	$
Insurance (not deducted from wages or included in mortgage payments)
Homeowner's or renter's: 	$ 	$
Life: 	$ 	$
Health: 	$ 	$
Motor vehicle: 	$ 	$
Other: 	$ 	$
Taxes (not deducted from wages or included in mortgage payments) (specify): $ 	$
Installment payments
Motor vehicle: 	$ 	$
Credit card (name): 	$ 	$
Department store (name): 	$ 	$
Other: 	$ 	$
Alimony, maintenance, and support paid to others 	$ 	$
Case 2:25-cv-02827-JAT--ASB Document 5 Filed 01/08/26 Page 17 of 18

Case 2:25-cv-02827-JAT--ASB Document5 Filed 01/08/26 Page 18 of 18

Page 5 of 5
AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
Regular expenses for operation of business, profession, or farm (attach detailed $ $
statement)
Other (specify): $ $
Total monthly expenses: 0.00/S 0.00

9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the

next 12 months?

OYes ONo If yes, describe on an attached sheet.
10. Have you spent — or will you be spending — any money for expenses or attorney fees in conjunction with this

lawsuit? OF Yes ONo

If yes, how much? $

11. Provide any other information that will help explain why you cannot pay the costs of these proceedings.

12. Identify the city and state of your legal residence.

Your daytime phone number:

Your age: Your years of schooling: