Free Certificate of Custodial Institution - New Hampshire

UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE

___________________________ v. ___________________________ Case No. _______________________

ATTACHMENT TO MOTION/AFFIDAVIT TO PROCEED IN FORMA PAUPERIS WITHOUT PREPAYMENT OF FEES CERTIFICATE OF CUSTODIAL INSTITUTION Name of Inmate: Name of Institution: Address of Institution: ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________

1.

I hereby certify that for the six-month period immediately preceding this

date the applicant has had average monthly deposits to his/her account of $_____________. 2. Further, I certify that for the six-month period immediately preceding this

date the applicant has maintained an average monthly balance in his/her account of $_____________. 3. I attach a certified copy of the applicant's trust account statement for the

six months preceding the submission of this certificate.

___________________________________ Authorized Officer of Institution __________________________________ Title ___________________________________ Date
USDCNH-14 (Revised 8-00) (Previous Editions Useable)