Ajala, Mustafa-El v. U.W. Hospital and Clinics et al

Filing 2

ORDER directing plaintiff to submit the filing fee or motion for ifp and Trust Fund Account Statement by 10/11/2016. Signed by Magistrate Judge Peter A. Oppeneer on 9/19/2016. (jef),(ps)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
MUSTAFA-EL K.A. AJALA,
f.k.a. Dennis E. Jones-El,
ORDER
Plaintiff,
v.

Case No. 16-cv-639-bbc

U.S. HOSPITAL AND CLINICS et al.,
Defendants.

Plaintiff Mustafa-El K.A. Ajala 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 $400 filing fee or submit a properly supported motion for
leave to proceed without prepayment of the filing fee no later than October 11, 2016.
A motion for leave to proceed without prepayment of the filing fee 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 date of the
complaint. 28 U.S.C. § 1915(a)(2). If I find that plaintiff is indigent, I will calculate an
initial partial payment amount that must be paid before the court can screen the merits of
the complaint under 28 U.S.C. § 1915(e)(2). Thereafter, plaintiff will be required to pay the
balance of the filing fee in installments.

ORDER
IT IS ORDERED that plaintiff Mustafa-El K.A. Ajala may have until October 11,
2016 to submit the $400 filing fee or a motion for leave to proceed without prepayment and
a trust fund account statement for the period beginning approximately March 13, 2016 and

ending approximately September 13, 2016.

If, by October 11, 2016, plaintiff fails to

respond to this order, I will assume that plaintiff wishes to withdraw this action voluntarily.
In that event, the case will be closed without prejudice to plaintiff filing the case at a later
date.

Entered this 19th day of September, 2016.
BY THE COURT:

PETER OPPENEER
Magistrate Judge

UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF WISCONSIN
MUSTAFA-EL K.A. AJALA,
ORDER

Plaintiff,
v.

Case No. 16-cv-639-bbc
U.S. HOSPITAL AND CLINICS,
Defendants.

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 sixmonth 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

If “yes,” list them below.

Name or initials (for
minor children only)

Relationship to You

Age

Amount of Support
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

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

□ No
$ ____________________

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).
______________________________________________________________________
______________________________________________________________________

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
(Plaintiffs and defendants)

Case number
(or year of filing)

Federal district

________________________

____________________

_______________________

________________________

____________________

_______________________

________________________

____________________

_______________________

________________________

____________________

_______________________

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