Free Final IFP FORM - Alaska

Name

Prison Number

Mailing Address, Zip Code, Place of Confinement

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ALASKA PRISONER'S APPLICATION TO WAIVE PREPAYMENT OF FEES CASE NO.
(To be supplied by the Court)

Plaintiff, vs. Defendant(s). I,

, declare that I am the (check the appropriate box)

9 Plaintiff (filing civil rights complaint) 9 Petitioner for writ of habeas corpus under 28 U.S.C. §§ 2254 or 2241

9 Appellant (on appeal to the Ninth Circuit) 9 Other

in this case. I am unable to prepay the fees for this proceeding or give security because of my poverty, and I believe I am entitled to the relief I am requesting. I agree that, if I am granted this application, a portion of any recovery, as directed by the Court, will be paid to the Clerk of Court for reimbursement of all unpaid fees and costs incurred by me in the case. In support of this application, I answer the following questions under penalty of perjury: 1. Are you currently incarcerated?

9 Yes

9 No (If "No" DO NOT USE THIS FORM)

If "Yes" state the place of your incarceration: IMPORTANT: Have the Department of Corrections fill out the Certification and Calculation portion of this application and attach a certified copy of your prison trust account statement showing transactions for the past six months. 2. Are you currently employed?

9 Yes

9 No

If the answer is "Yes," state both your gross and net salary or wages per month, and give the name and address of your employer: Gross: Employer: Net:

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Prisoner Fees

If the answer to No. 2 is "No," state the date of last employment and the amount of the gross and net salary and wages per month which you received. Gross: Employer: Date of Last Employment: 3. / / (month/day/year) Net:

In the past twelve months have you received any money from any of the following sources? a. b. c. d. e. f. Business, profession or other self-employment Rent payments, interest, dividends or PFDs Pensions, annuities or life insurance payments Disability or worker's compensation payments Gifts or inheritances Any other sources

9 Yes 9 Yes 9 Yes 9 Yes 9 Yes 9 Yes

9 No 9 No 9 No 9 No 9 No 9 No

If the answer to any of the above is "Yes," describe each source and state the amount and when received and what you expect you will continue to receive.

4. 5.

Do you have any cash? 9 Yes State the total amount and location: Do you have any checking account(s)? a.

9 No 9 Yes 9 No

Name(s) and address(es) of bank(s):

b. 6.

Present balance(s) in account(s):

Do you have any savings/IRA/money market/CDs' separate from checking accounts? 9 Yes 9 No a. Name(s) and address(es) of financial institution(s)

b. 7.

Present balance(s) in account(s):

Do you own an automobile or other motor vehicle? a. Make: Year: b. Is it financed? 9 Yes 9 No c. If so, what is the amount owed?

9 Yes 9 No
Model:

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Prisoner Fees

8.

Do you own any real estate, stocks, bonds, securities, other financial instruments or other 9 Yes 9 No valuable property? If "Yes" describe the property and state its value:

9.

Do you have any other assets or personal property other than clothing? If "Yes" list the asset(s) and state the value of each asset listed:

9 Yes 9 No

10.

Have you placed any property, assets or money in the name or custody of anyone else in the last two years? 9 Yes 9 No If the answer is "Yes," give the date, describe the property, assets or money, give the name of the person given custody of the item and the reason for the transfer:

11.

List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their monthly support (and for minor children, use initials only): Name Name Name Name Relationship Relationship Relationship Relationship DECLARATION UNDER PENALTY OF PERJURY Support: $ Support: $ Support: $ Support: $

I declare under penalty of perjury under the laws of the United States of America that the above information is true and correct.
Executed on: DATE SIGNATURE OF APPLICANT

THE CERTIFICATION & CALCULATION ON THE FOLLOWING PAGE MUST BE COMPLETED!

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Prisoner Fees

AUTHORIZATION I, , request and authorize the agency holding me

in custody to prepare for the Clerk of the United States District Court for the District of Alaska, a certified copy of the statement for the past six months of my trust fund account (or institutional equivalent) activity at the institution where I am incarcerated. I further request and authorize the agency holding me in custody to calculate and disburse funds from my trust fund account (or institutional equivalent) pursuant to any future orders issued by the Court relating to this civil action in accordance with 28 U.S.C. § 1915(b).

DATE

SIGNATURE OF APPLICANT

COMMITTED NAME OF APPLICANT (Type or Print)

INMATE NO.

CERTIFICATION AND CALCULATION (To be completed by the Department of Corrections) I certify that the applicant has the (available) sum of $ credit at (name of institution). on account to his/her

I certify that during the past six months, the average monthly deposits to the applicant's account was $ , and 20% of that is $ .

I further certify that during the past six months, the average monthly balance in the applicant's account was $ , and 20% of that is $ .

Please attach certified copy of applicant's account statement showing transactions for past six months.

DATE

SIGNATURE OF AUTHORIZED OFFICER

TITLE and NAME OF AGENCY

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Prisoner Fees