Perez, Samuel v. Thomas, Tim et al

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN

SAMUEL PEREZ,

Plaintiff,
v.

WARDEN TIM THOMAS,
SECURITY DIRECTOR R GIROUX,
SGT ALEXANDER MORA,
OFFICER DAVID RODICH,
C.O. BOUCHETTE,
C.O. WILSON,
UNIT MANAGER K LOBENSTINE,

Defendants.

ORDER

Case No. 2
6-cv-759-wmc

Plaintiff Samuel Perez has filed a proposed civil complaint, but has neither paid the
filing fee, nor requested leave to proceed without prepayment. For this case to proceed,
plaintiff must pay the $405 filing fee
1
or submit a properly supported motion for leave to
proceed without prepayment by September 11, 2026.
A motion for leave to proceed without prepayment must be accompanied by a certified
copy of plaintiff’s inmate trust fund account statement (or institutional equivalent) for the six-
month period immediately preceding the filing of the complaint. 28 U.S.C. § 1915(a)(2). If I
find that plaintiff is indigent, I will calculate an initial partial payment of the filing fee that
plaintiff must pay before the court can screen the complaint on the merits under 28 U.S.C. §
1915(e)(2). Thereafter, plaintiff must pay the balance of the filing fee in installments.

1
Effective December 1, 2023, the cost to file a civil action in federal court is $405 — a $350 statutory
fee plus a $5 5 administrative fee that does not apply to persons granted in forma pauperis status under
28 U.S.C. § 1915.
Case: 3:26-cv-00759-wmc Document #: 3 Filed: 08/14/26 Page 1 of 5

ORDER
IT IS ORDERED that plaintiff Samuel Perez may have until September 11, 2026 to
submit the $405 filing fee or a motion for leave to proceed without prepayment and a trust
fund account statement for the period beginning approximately February 14, 2026 and ending
approximately August 14, 2026. If plaintiff fails to respond to this order by September 11,
2026, then I will assume that plaintiff wishes to withdraw this action voluntarily. In that event,
the case will be dismissed without prejudice to plaintiff refiling at a later date.

Entered this 14
th
day of August 2026.

BY THE COURT:

s/

ANDREW R. WISEMAN
United States Magistrate Judge
Case: 3:26-cv-00759-wmc Document #: 3 Filed: 08/14/26 Page 2 of 5

UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN

SAMUEL PEREZ,

Plaintiff,
v.

WARDEN TIM THOMAS,
SECURITY DIRECTOR R GIROUX,
SGT ALEXANDER MORA,
OFFICER DAVID RODICH,
C.O. BOUCHETTE,
C.O. WILSON,
UNIT MANAGER K LOBENSTINE,

Defendants.

ORDER

Case No. 26-cv -759-wmc

PRISONER REQUEST TO PROCEED IN DISTRICT COURT
WITHOUT PREPAYING THE FULL FILING FEE

Answer the following questions to the best of your ability.
Note: If you do not tell the truth, the court may dismiss your lawsuit.

I. Personal Information

1) Your name: ___________________________________________________________

(a) State the place of your incarceration and provide your prisoner identification
number:

_______________________________________ _____________________________
(place) (number)

(b) Are you employed at the institution? □Yes □ No

(c) Do you receive any payment from the institution? □Yes □ No

Attach a printout of your prison trust account statement showing transactions for the six-
month period immediately preceding the filing of this request and showing the current
balance of your account.

2) Do you have any dependents that you are responsible for supporting?

□ Yes □ No

Case: 3:26-cv-00759-wmc Document #: 3 Filed: 08/14/26 Page 3 of 5

If “yes,” list them below.

Name or initials (for Relationship to You Age Amount of Support
minor children only) Provided per Month

________________________ _________________ ________ $____________

________________________ _________________ ________ $____________

________________________ _________________ ________ $____________

II. Property or Assets: - If you are married, your answers must include your spouse's
property.

1 ) Do you own a car?

□ Yes □ No If “yes,” list the car(s) below:

Make and Model Year Approximate Current
Value

_______________________________________________ __________ $________________

_______________________________________________ __________ $________________

2) Do you own your home(s)? □ Yes □ No

If “Yes,” state the approximate value(s). $ ____________________

What is the amount of equity (assessed value of residence minus outstanding
mortgage balance) in the home(s)? $ ____________________

3) Do you have any cash or checking, savings, or other similar accounts?
□ Yes □ No

If “Yes,” state the total of such sums. $ ____________________

4) Do you own any other property of value, such as real estate, stocks, bonds, trusts, or
individual retirement accounts (e.g., IRA, 401 k), artwork, or jewelry?

□ Yes □ No

If “Yes,” describe the property and the approximate value(s).

______________________________________________________________________

Case: 3:26-cv-00759-wmc Document #: 3 Filed: 08/14/26 Page 4 of 5

______________________________________________________________________

III. Litigation History

For each federal lawsuit that you recall having filed, list as much of the following
information that you remember about each case: The name of the case (that is, the plaintiffs and
the defendants), the case number or year of filing, and the federal district in which you filed the
case. Use more paper if needed.

Case Name Case number Federal district
(Plaintiffs and defendants) (or year of filing)

________________________ ____________________ _______________________

________________________ ____________________ _______________________

________________________ ____________________ _______________________

________________________ ____________________ _______________________

IV. Other Circumstances - Describe any other financial circumstance(s) that you would
like the court to consider when reviewing this petition.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

I, ____________________, declare that I am the plaintiff bringing this complaint. I declare that
I am unable to prepay the full filing fee and that I am entitled to the relief sought in the
complaint.

___________________________ _________________________________________
Date Signature - Signed Under Penalty of Perjury
Case: 3:26-cv-00759-wmc Document #: 3 Filed: 08/14/26 Page 5 of 5