1 NA 2 WO 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA 8 9 Rodney Woodville, No. CV 21-00021-PHX-DGC (DMF) 10 Plaintiff, 11 v. ORDER 12 ASDD Documents Destruction, 13 Defendant.
14 15 Plaintiff Rodney Woodville, who is confined in the Arizona State Hospital, has filed 16 a pro se document entitled “Petition for Emergency Injunction” (Doc. 1). The Court will 17 dismiss this action without prejudice. 18 I. Petition for Emergency Injunction 19 In his Petition, Plaintiff alleges that “hospital employees” intentionally disposed of 20 “[d]ocuments containing potential evidence of health care violations and other criminal 21 activity.”1 Plaintiff asks the Court to “issue an injunction order that the aforementioned 22 receptacle be seized and held by the Court until federal investigators can be apprised of the 23 24
25 1 Plaintiff cites 18 U.S.C. § 1518 as the basis for his claim. Section 1518 provides 26 a criminal penalty for any person who “willfully prevents, obstructs, misleads, delays or attempts to prevent, obstruct, mislead, or delay the communication of information or 27 records relating to a violation of a Federal health care offense to a criminal investigator.” See 18 U.S.C. § 1518(a). Section 1518 does not provide a basis for civil liability. See 28 Aldabe v. Aldabe, 616 F.2d 1089, 1092 (9th Cir. 1980) (finding statutes that provide for punishment by fine or imprisonment do not create private rights of action, give rise to civil liability, or provide a basis for lawsuits pursuant to the Civil Rights Act) 1 situation and secure the contents of the receptacle.” Plaintiff states the contents of the 2 receptacle will be shredded by Defendant. 3 II. Legal Standard 4 The standards for a preliminary injunction and a temporary restraining order are 5 substantially the same. Stuhlbarg Int’l Sales Co., Inc. v. John D. Brush & Co., Inc., 240 6 F.3d 832, 839 n.7 (9th Cir. 2001). “A preliminary injunction is ‘an extraordinary and 7 drastic remedy, one that should not be granted unless the movant, by a clear showing, 8 carries the burden of persuasion.’” Lopez v. Brewer, 680 F.3d 1068, 1072 (9th Cir. 2012) 9 (quoting Mazurek v. Armstrong, 520 U.S. 968, 972 (1997) (per curiam); see also Winter v. 10 Natural Res. Def. Council, Inc., 555 U.S. 7, 24 (2008) (citation omitted) (“[a] preliminary 11 injunction is an extraordinary remedy never awarded as of right”). A plaintiff seeking a 12 preliminary injunction must show that (1) he is likely to succeed on the merits, (2) he is 13 likely to suffer irreparable harm without an injunction, (3) the balance of equities tips in 14 his favor, and (4) an injunction is in the public interest. Winter, 555 U.S. at 20. “But if a 15 plaintiff can only show that there are ‘serious questions going to the merits’—a lesser 16 showing than likelihood of success on the merits—then a preliminary injunction may still 17 issue if the ‘balance of hardships tips sharply in the plaintiff’s favor,’ and the other two 18 Winter factors are satisfied.” Shell Offshore, Inc. v. Greenpeace, Inc., 709 F.3d 1281, 1291 19 (9th Cir. 2013) (quoting Alliance for the Wild Rockies v. Cottrell, 632 F.3d 1127, 1135 (9th 20 Cir. 2011)). Under this serious questions variant of the Winter test, “[t]he elements . . . 21 must be balanced, so that a stronger showing of one element may offset a weaker showing 22 of another.” Lopez, 680 F.3d at 1072. Regardless of which standard applies, the movant 23 “has the burden of proof on each element of the test.” See Envtl. Council of Sacramento v. 24 Slater, 184 F. Supp. 2d 1016, 1027 (E.D. Cal. 2000). 25 Motions for injunctive relief are not independent actions but, rather, a means to seek 26 extraordinary relief in an ongoing action that has been initiated by filing a complaint or 27 other proper petition that alleges jurisdictional facts. Indeed, Rule 65 of the Federal Rules 28 of Civil Procedure, which provides for the granting of preliminary injunctions and 1 temporary restraining orders, “was designed solely as a procedural tool to expedite the 2 action and accommodate the court and the litigants” and “does not confer either subject 3 matter or personal jurisdiction on the court.” Citizens Concerned for the Separation of 4 Church and State v. City and County of Denver, 628 F.2d 1289, 1299 (10th Cir. 1980). 5 Before seeking injunctive relief, Plaintiff must first have a Complaint pending before the 6 Court. See Stewart v. United States Immigration & Naturalization Serv., 762 F.2d 193, 7 198 (2d Cir. 1985) (“Only after an action has been commenced can preliminary injunctive 8 relief be obtained.”); see also Devose v. Herrington, 42 F.3d 470, 471 (8th Cir. 1994) (per 9 curiam) (a party seeking injunctive relief must establish a relationship between the claimed 10 injury and the conduct asserted in the complaint). 11 III. Discussion 12 Because Plaintiff has not filed a Complaint, his Petition for Emergency Injunction 13 is not properly before the Court. Even if Plaintiff’s Petition had been properly presented, 14 he has not shown that he is entitled to injunctive relief under the standard set forth above. 15 First, Plaintiff’s allegations are too vague to conclude that he is likely to succeed on 16 any constitutional claims. Second, Plaintiff has failed to show that he is likely to suffer 17 irreparable harm in the absence of a temporary restraining order. Although Plaintiff states 18 “the healthcare violations that [he] intends to report appear to pose an imminent risk to the 19 welfare of patients at the Arizona State Hospital, he does not allege any facts to suggest 20 that this fear is well-grounded. Even assuming the documents will be permanently 21 disposed of, Plaintiff has not cited any factual support for his conclusion that he personally 22 would be endangered if the contents of the receptacle are shredded. Accordingly, the Court 23 will deny the Petition for Emergency Injunction and direct the Clerk of Court to close this 24 case. 25 Plaintiff is not precluded from filing a motion for an injunction or a temporary 26 restraining order in a new case, so long as he first files a civil rights complaint on a court- 27 approved form and either pays the filing and administrative fees or files a complete 28 Application to Proceed In District Court Without Prepaying Fees or Costs. The Court will 1) 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 District Court Without Prepaying Fees or Costs. 4 IT IS ORDERED: 5 (1) ‘Plaintiff's Petition for Emergency Injunction (Doc. 1) is denied without 6| prejudice. The Clerk of Court must close this action. 7 (2) The Clerk of Court must send Plaintiff the court-approved form for filing a 8 | civil rights complaint and the court-approved form for filing an Application to Proceed In District Court Without Prepaying Fees or Costs. 10 Dated this 14th day of January, 2021. 11 Le 12 pee 6 Cou pel 13 David G. Campbell 14 Senior United States District Judge 15 16 17 18 19 20 21 22 23 24 25 26 27 28
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 $402.00 ($350.00 filing fee plus $52.00 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. Mail the original and one copy of the complaint with the $402 filing and administrative fees or the application to proceed in forma pauperis to:
1 Revised 12/1/20 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.
2 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.
3 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.
4 ___________________________________________ 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. CASE NO. __________________________________ (To be supplied by the Clerk) (1) _______________________________________ ,
(Full Name of Defendant) CIVIL RIGHTS COMPLAINT (2) _______________________________________ , BY A PRISONER
(3) _______________________________________ , G Original Complaint (4) _______________________________________ , G First Amended Complaint G Second Amended Complaint Defendant(s).
G Check if there are additional Defendants and attach page 1-A listing them.
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: .
550/555 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. 2 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. .
3 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. .
4 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.
5 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.
6 AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form) UNITED STATES DISTRICT COURT for the __________ District of __________ ) Plaintiff/Petitioner ) v. ) Civil Action No. ) Defendant/Respondent ) APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Long Form) Affidavit in Support of the Application Instructions I am a plaintiff or petitioner in this case and declare Complete all questions in this application and then sign it. that I am unable to pay the costs of these proceedings Do not leave any blanks: if the answer to a question is “0,” and that I am entitled to the relief requested. I declare “none,” or “not applicable (N/A),” write that response. If under penalty of perjury that the information below is you need more space to answer a question or to explain your true and understand that a false statement may result in answer, attach a separate sheet of paper identified with your a dismissal of my claims. name, your case's docket number, and the question number. Signed: 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 Income amount expected amount during the past 12 next month months You Spouse You Spouse Employment $ $ $ $ Self-employment $ $ $ $ Income from real property (such as rental income) $ $ $ $ Interest and dividends $ $ $ $ Gifts $ $ $ $ Alimony $ $ $ $ Child support $ $ $ $ AO 239 (01/09) 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. AO 239 (01/09) 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 Amount owed to you Amount owed to your spouse money $ $ $ $ $ $ 7. State the persons who rely on you or your spouse for support. Name (or, if under 18, initials only) Relationship Age Page 4 of 5 AO 239 (01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)
spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. ee “Saceec ee ff Are real estate taxes included? [ Yes No $ $ Is property insurance included? [1 Yes ( No
Insurance (not deducted from wages or included in mortgage payments) ee Homeowner's or renter's:
Installment payments ee
Credit card (name): Department store (name):
Page 5 of 5 AO 239 (01/09) 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)
. Total monthly expenses: 9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months? Yes Ol No If yes, describe on an attached sheet. 10. Have you paid — or will you be paying — an attorney any money for services in connection with this case, including the completion of this form? [1 Yes No If yes, how much? $ If yes, state the attorney's name, address, and telephone number:
11. Have you paid — or will you be paying — anyone other than an attorney (such as a paralegal or a typist) any money for services in connection with this case, including the completion of this form? O Yes If yes, how much? $ If yes, state the person's name, address, and telephone number:
12. Provide any other information that will help explain why you cannot pay the costs of these proceedings.
13. Identify the city and state of your legal residence.
Your daytime phone number: Your age: Your years of schooling: Last four digits of your social-security number: