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Prisoners Petition For Waiver Of Prepayment Of Fees-Costs - Affidavit Of Indigency CV-438 - Wisconsin
| Prisoners Petition For Waiver Of Prepayment Of Fees-Costs - Affidavit Of Indigency Form. This is a Wisconsin form and can be used in Civil Circuit Court Statewide . |
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FORM SUMMARY Name of Form: Prisoners Petition for Waiver of Prepayment of Fees/Costs Affidavit of Indigency Form Number: CV-438 Statutory Reference: 814.29, Wisconsin Statutes Benchbook Reference: CV 46-3 Purpose of Form: For a prisoner to seek to begin an action or special proceeding without prepayment of filing fees, costs, or security for costs. Who Completes It: Prisoner completes the affidavit portion. Distribution of Form: Original to court file, copy (to be provided by prisoner) to be sent to the Department of Justice after the court enters an order (CV-439). Accompanying Forms: The prisoner is required to provide two complete copies of the affidavit of indigency and other attachments. The attachments are to be: [if the proposed action applies to prison or jail conditions] documentation showing exhaustion of all available administrative remedies. a certified copy of the prisoners trust fund account for the last six months. authorization in writing to the agency having custody of the prisoners trust fund account to forward payments from that account to cover filing fees and costs. The prisoner must also provide sufficient copies of the summons/complaint/petition to be potentially served on the defendants/respondents. New Form/Modification: Modification, last update 12/01. Modifications: In item #1, added word prepayment so line reads ..and request waiver of prepayment of those costs because of poverty. Comments: The new prison litigation law (1997 Wisconsin Act 133) becomes effective September 1, 1998. This law creates significantly different procedural requirements for a prisoner seeking to commence an action or special proceeding without prepayment of filing fees, costs, or security for costs. Because of the different decisions that must be made by the court, this specialized form must be used in lieu of CV- 410, the general Petition for Waiver of Fees/CostsAffidavit of Indigency and Order. Date: 06/02/03 Page 1 <<<<<<<<<********>>>>>>>>>>>>> 2 The major distinction between a prisoners affidavit of indigency and a nonprisoners affidavit (using CV-410) are: There is no automatic eligibility section comparable to section 1 on CV-410. The prisoner must complete the financial information. The prisoner must attach a certified copy of the prisoners trust fund account for the last six months. The prisoner must include written documentation that the available administrative remedies have been fully exhausted. The prisoner must affirmatively show that she/he has not had more that three dismissals for any of the reasons listed in 802.05(3)(b)1-4, Wisconsin Statutes, in any state or federal court of an appeal, writ or error, action, or special proceeding. The department of justice will be maintaining a database of prisoner litigation and will provide to prisoners a certification showing the number of such dismissals. As with a nonprisoners affidavit (using CV-410), the prisoner must attach a copy of the pleadings. For a more detailed statement of the courts duties upon receipt of a prisoners affidavit, see form summary for the court order CV-439. If a prisoner is alleging that he/she is in imminent danger of physical harm, a separate petition (CV-440) and court order (CV-441) should be used because the factors that the prisoner and court must consider are different. About this form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Courts Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Date: 06/02/03 Page 2 <<<<<<<<<********>>>>>>>>>>>>> 3 For Official Use STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Please Print or Type Prisoners Petition for Waiver of Prepayment of Fees/Costs -vs- Affidavit of Indigency Case No. (The prisoner must provide the following to the Clerk of Court at the time of filing: The original and one copy of this affidavit and attachments. Sufficient copies of the pleadings for potential service on all named defendants.) Under oath I state that: 1. I am unable to pay the costs of this action, special proceeding or appeal or to give security for those costs, and request waiver of prepayment of those costs because of poverty. 2. I have not had three or more appeals, writs of error, actions or special proceedings dismissed by a state or federal court for any of the reasons listed in 802.05(3)(b)1-4, Wisconsin Statutes. Attached is the original Wisconsin Department of Justice certification (form DJ-LS-22 containing the raised seal) dated within 30 days of the date of this petition concerning the number of appeals, writs of error, actions or special proceedings dismissed by a state or federal court. 3. I have attached and incorporated into this affidavit: The original pleading in this matter. [If this proceeding is related to prison or jail conditions]: Written documentation of exhaustion of all available administrative remedies, including copies of all written materials: I provided to the administrative agency as part of the administrative proceeding; the administrative agency provided to me related to the administrative proceeding; and, included as part of any administrative appeal. A certified copy of my prison trust fund account for the six months preceding the date of this petition. My authorization to the agency having custody of my prison trust fund account (on DOC form 1930 provided by the Wisconsin Department of Corrections), to forward payments from my account to the clerk of court each time the amount in the account exceeds $10, until the costs and fees are paid in full. 4. I have have not committed an offense on or after September 1, 1998. (An offense is defined in 165.83(1)(c), Wisconsin Statutes, as an act which is a felony, misdemeanor, or violation of a city, county, village, or town ordinance. 5. I am am not employed. Name of employer: 6. I earn $ gross weekly. every two weeks. twice monthly. monthly. 7. I have received or been entitled to receive money from the following sources within the past 12 months (list total amount): pension, annuities or life insurance payments:.............$ disability or workers compensation payments: ............$ gifts, loans or inheritances: ......................................$ rent payments, interest or dividends:............................$ business, profession or self employment:
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