Free Motion for Leave to Proceed in forma pauperis - District Court of Delaware - Delaware

Case1:05—cv-0 0 ·‘· D0cument1 Fil 05/1 /2005 Page10f4
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Case 1:05-cv-00307-KAJ Document 1 Filed 05/17/2005 Page 3 of 4
(Note to Applicant: fonrvard a copy of this Account Certification Form to each Institution in which you
have been confined for the six-month period prior to the date of this application.)
___....»-— -: »- -
ACCOUNT CERTIFICATION FORM
I certify that the attached Yust fund account statement (or in a!-·eq¤iVaiept) is true and correct.
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__ Au ‘•fticer of Institution
NOTICE TO PRISON OFFICIALS: Pursuant to the Prison Litigation Reform Act, you will be obligated
to forward payments to the appropriate United States District Court if the prisoner herein is granted leave
to proceed Q forma gaugeris. 28 U.S.C. § 1915(b)(2) (April 26, 1996). Pursuant to that statute, once an
initial partial lee is paid, the prison official in charge of the prisoners account must forward payments of
20% of the income credited to the prisoners account during the preceding month, each month the
amount in the account exceeds $10.00, until the entire filing fee has been paid.
(Cutafongdoffedfine) - - unnu--H--U g
(Note to Applicant: forward a copy of this Account Certification Form to each institution in which you j
have been confined for the six-month period prior to the date of this application.)
ACCOUNT CERTIFICATION FORM
I certify that the attached trust fund account statement (or Institutional equivalent) is tnre and correct.
I
Date _ _ Authorized Officer of Institution
" I

NOTICE TO PRISON OFFICIALS: Pursuant to the Prison Litigation Refomi Act, you will be obligated ,
to forward payments to the appropriate United States District Court if the prisoner herein is granted leave .
to proceed ig forma gaugeris. 28 U.S.C. § 1915(b)(2) (April 26, 1996). Pursuant to that statute, once an r
initial partial fee is paid, the prison official In charge of the prisoners account must forward payments of I
20% of the income credited to the prisoners account during the preceding month, each month the I
amount in the account exceeds $10.00, until the entire filing fee has been paid. e


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