Official Federal Forms > Circuit Court Of Appeals > 4th Circuit Court Of Appeals
PLRA Application - Official Federal Forms
| PLRA Application Form. This is a national form and can be used in 4th Circuit Court Of Appeals Circuit Court Of Appeals . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT 1100 East Main Street, Suite 501 Richmond, Virginia 23219-3517 www.ca4.uscourts.gov ___________________________________________ PLRA APPLICATION TO PROCEED WITHOUT PREPAYMENT OF FEES ___________________________________________ No. ___________, _________________v.____________________________ ______________________________ (lower court case no.) I,_________________________ , being first duly sworn, depose and say that I am the _______________, in the above-entitled case; that in support of my application to proceed without being required to prepay fees or give security therefor, I state that because of my poverty I am unable to prepay the costs of said proceeding or to give security therefor; that I believe I am entitled to redress; and that the issues I desire to present in this case are the following: I make this application with the understanding that I am liable under 28 U.S.C. Section 1915 for payment of the full filing fee and that the fee will be collected and paid from my prison trust account. I understand that if I have, while incarcerated, filed three or more prior actions or appeals which were dismissed by a federal court as frivolous, malicious, or for failure to state a claim, I am required to prepay the full fee unless I am under imminent danger of serious physical injury. 1. Have you filed, while incarcerated, three actions or appeals which were dismissed as frivolous, malicious, or for failure to state a claim? [ ]Yes [ ]No a. If the answer is yes, list the case numbers and names for all actions or appeals which were dismissed as frivolous, malicious, or for failure to state a claim. b. If the answer is yes, state the facts in support of any claim that you are under imminent danger of serious physical injury. 2. Are you presently employed? [ ]Yes [ ]No a. If the answer is yes, state the amount of your salary or wages per month and give the name and address of your employer. American LegalNet, Inc. www.FormsWorkFlow.com b. If the answer is no, state the date of your last employment and the amount of the salary and wages per month which you received. 3. Have you received within the past twelve months any income from a business, profession or other form of self-employment, or in the form of rent payments, interest dividends, or other source? [ ]Yes [ ]No a. If the answer is yes, describe each source of income, and state the amount received from each during the past twelve months. 4. Do you own any cash or checking or savings accounts? [ ]Yes [ ]No a. If the answer is yes, state the total value of the items owned. 5. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding ordinary household furnishings and clothing)? [ ]Yes [ ]No a. If the answer is yes, describe the property and state its approximate value. 6. List the persons who are dependent upon you for support and state your relationship to those persons. 7. Attach Consent to Collection of Fees from Trust Account form and give Trust Account Statement form to trust officer for completion and return to you. Forward completed Trust Account Statement to Court of Appeals. I declare under penalty of perjury that the above information is true and correct. Signature of Applicant: ___________________ Date: ________________________________ CERTIFICATE OF SERVICE ********************** I certify that on _______________, I served a copy of this PLRA Application on all parties, addressed as shown [list parties' names and the addresses at which they were served below]: Signature: _________________________ 09/12/2011 SCC American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
