Jackson, Pearlie v. Miller, C.L. et al

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
PEARLIE BERNARD JACKSON ,
Plaintiff,
v.
OFFICER C.L. MILLER, et al.,
Defendants.
ORDER
Case No. 26-cv-207-jdp
Plaintiff Pearlie Bernard Jackson has filed a proposed complaint. 	Plaintiff seeks to
commence this lawsuit without prepayment of the filing fee pursuant to 28 U.S.C. § 1915.
From plaintiff’s affidavit of indigency, I cannot determine whether plaintiff qualifies for
indigent status. The affidavit is missing the last two pages of the form. Without these pages,
I am unable to determine whether plaintiff qualifies for indigent status. 	Therefore, I will
provide plaintiff with the opportunity to supplement the request for leave to proceed without
paying the filing fee by completing the enclosed affidavit of indigency.
ORDER
IT IS ORDERED that plaintiff Pearlie Bernard Jackson, may have until April 6, 2026,
to amend and return the affidavit of indigency. 	If plaintiff fails to provide this requested
financial information, then the court will deny the request for leave to proceed without
prepayment of the filing fee for failure to show indigency.
Entered this 17th day of March, 2026.
BY THE COURT:
/s/
ANDREW R. WISEMAN
United States Magistrate Judge
Case: 3:26-cv-00207-jdp Document #: 3 Filed: 03/17/26 Page 1 of 5

UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
PEARLIE BERNARD JACKSON ,
Plaintiff,
v.
OFFICER C.L. MILLER, et al.,
Defendants.
ORDER
Case No. 26-cv-207-jdp
NON-PRISONER REQUEST TO PROCEED IN DISTRICT COURT
WITHOUT PREPAYING THE 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) 	Are you employed? 	□Yes 	□ No
2) 	Are you married? 	□ Yes 	□ No
If “Yes,” is your spouse employed? 	□ Yes 	□ No
3) 	Do you have any dependents that you are responsible for supporting?
□ Yes 	□ No
If “Yes,” list them below:
Name or initials (for 	Relationship to You 	Age 	Amount of Support
minor children only) 	Provided per Month
________________________ 	_________________ 	________ 	$____________
________________________ 	_________________ 	________ 	$____________
________________________ 	_________________ 	________ 	$____________
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II. 	Income - If you are married, your answers must include your spouse's income.
(When calculating income, include any wages, salary, rent, child support, public
assistance, unemployment compensation, disability payments, life insurance payments,
pensions, annuities, workers' compensation, stock dividends and interest, gifts and
inheritance, or other money you receive from any source.)
1) 	State your total monthly wages or salary? 	$ ______________
2) 	Provide the name and address of your employer(s):
______________________________________________________________
3) 	State your spouse's total monthly wages or salary? 	$ ______________
State the amount of money you have received from any other source in the last twelve months,
such as the sources listed above. Please attach an additional sheet if necessary.
Source of income 	Amount
______________________________________________ 	$ ______________________
______________________________________________ 	$ ______________________
III. 	Expenses - If you are married or have dependents, your expenses should also include
your household's expenses.
(When calculating household expenses, you may include groceries, clothing, medical
costs, utilities that are not included in your rental payments, transportation, and
insurance.)
1) 	Identify the following amounts that you pay per month:
□ Rent or 	□ Mortgage 	$ __________________________________
Car payment(s) 	$ __________________________________
Alimony or court-ordered child support 	$ __________________________________
Credit card payment(s) 	$ __________________________________
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2) 	Do you have any other monthly expenses that you have not already listed?
□ Yes 	□ No
If “Yes,” list them below:
Expense 	Amount
____________________________ 	$ __________________________________
____________________________ 	$ __________________________________
____________________________ 	$ __________________________________
3) 	What are your total monthly expenses? 	$___________________________________
IV. 	Property - If you are married, your answers must include your spouse's property.
1) 	Do you own a car? 	□ Yes 	□ No 	If “Yes,” list 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. 	$_____________________________
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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).
________________________________________________________________
V. 	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 fee and that I am entitled to the relief sought in the
complaint.
___________________________ 	_________________________________________
Date 	Signature - Signed Under Penalty of Perjury
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