Deiss, Lacey v. Erickson, Sheila et al

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
LACEY DEISS ,
Plaintiff,
v.
SHEILA ERICKSON, et al.,
Defendants.
ORDER
Case No. 26-cv-229-wmc
Plaintiff Lacey Deiss 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 indicates that plaintiff is unemployed and has no income,
however, plaintiff does not include information regarding paying for basic living expenses, such
as food, clothing and shelter. 	Without this information, 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. 	When completing the affidavit, plaintiff should take care to
show how basic necessities are paid, and include plaintiff’s actual gross monthly income from
all sources for the last 12 months.
ORDER
IT IS ORDERED that plaintiff Lacey Deiss, may have until April 9, 2026, to amend
and return the affidavit of indigency, taking particular care to show how basic necessities are
paid, and include actual gross monthly income from all sources for the last 12 months. 	If
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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 ____ day of ____________, 20____.
BY THE COURT:
ANDREW R. WISEMAN
United States Magistrate Judge
Case: 3:26-cv-00229-wmc Document #: 3 Filed: 03/18/26 Page 2 of 6

UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
LACEY DEISS ,
Plaintiff,
v.
SHEILA ERICKSON, et al.,
Defendants.
ORDER
Case No. 26-cv-229-wmc
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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