Free Application for Exemption from Filing Fee - Alaska

IN THE COURT OF APPEALS OF THE STATE OF ALASKA
APPLICATION FOR EXEMPTION FROM FILING FEE For Use in Prisoner Civil Appeals Against the State of Alaska Under AS 9.19.010 - 100
Print Form

Instructions: Complete only if Appellant seeks a filing fee exemption under AS 9.19.010. If a filing fee exemption is sought, this form must be completed, and the documents listed in Item 3 must be attached. A waiver of cost bond must be sought by separate motion. 1. Appellant's Name: 2. Appellant's Affidavit: a. I am a prisoner as defined in AS 33.30.901. b. My complete financial situation, including my income, assets and court ordered payments is accurately and fully set out in the attached Supreme Court/Court of Appeals Financial Statement Form. c. The following circumstances prevent me from paying a full filing fee:

(Continue on this explanation Continue back if necessary.) d. Nature of the action or appeal (Include specific facts that, if proved, would entitle Appellant to a reversal on appeal):

Continue back if necessary.) (Continue on this explanation

3. Attached documents: a. Supreme Court/Court of Appeals Financial Statement. b. Certified copy of Appellant account statement from the Department of Corrections for the six-month period preceding the date of this application. 4. Oath: I declare under oath that all statements made in this application are true. ___________________________________ Date ________________________________________________________ Appellant's Signature

Subscribed and sworn to or affirmed before me on _________________________, 19_____ in _________________________ Alaska. _______________________________________________________ (SEAL) Notary Public My commission expires: ___________________________________ Proof of Service: I certify that on ___________________________ a copy of this application and attachments was mailed to ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Signature: _______________________________________________
COA - 919app(rev.1/98)

Continuation of Application for Exemption from Filing Fee 2. c. The following circumstances prevent me from paying a full filing fee (continued):

2. d. Nature of the action of appeal (continued):

COA - 919app - 2 (rev. 1/98)