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Prisoners Petition For Waiver Of Prepayment Of Fees-Costs Based On Imminent Danger - Affidavit Of Indigency CV-440 - Wisconsin
| Prisoners Petition For Waiver Of Prepayment Of Fees-Costs Based On Imminent Danger - 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 Based on Imminent Danger - Affidavit of Indigency Form Number: CV-440 Statutory Reference: 814.29, Wisconsin Statutes Benchbook Reference: CV 46-4 Purpose of Form: To allow a prisoner who claims to be in imminent danger of serious physical harm and who seeks 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-441). Accompanying Forms: The prisoner is required to provide two complete copies of the affidavit of indigency and other attachments. The attachments are documentation that the prisoner has completed the exhaustion of all available administrative remedies if required. Exhaustion is required if the underlying proposed action relates to prison or jail conditions. The prisoner is not required to provide either: a certified copy of the prisoners trust fund account statement, or, a certification from the Department of Justice (JD-SL-22) concerning the number of prior dismissals. The prisoner must also provide sufficient copies of the summons/complaint/petition for potential service on the defendants/respondents. New Form/Modification: Modification, last update 12/01. Modifications: Deleted duplicate wording prepayment of in title. Previous modification: Added word prepayment to title, which now reads Prisoners Petition for Waiver of Prepayment of Fee/Costs Based on Imminent Danger - Affidavit of Indigency. 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 Date: 01/08/02 Page 1 <<<<<<<<<********>>>>>>>>>>>>> 2 made by the court, this specialized form must be used in lieu of CV- 410, the general Petition for Waiver of Fees/Costs--Affidavit of Indigency and Order. The new law prohibits a prisoner from filing an action without prepayment of fees and costs when the prisoner has accumulated three or more dismissals under 802.05(3)(b)1-4, Wisconsin Statutes. However, if a prisoner is claiming imminent danger of serious physical injury, the three dismissals rule does not apply. The prisoner is still required to comply with all other procedural requirements, including: exhaustion of available administrative remedies, if the underlying proposed action involves prison or jail conditions; and, completion of the financial portion of the affidavit. authorization in writing to the agency having custody of the prisoners trust fund account (on DOC form 1930 provided by the Wisconsin Department of Corrections) to forward payments from that account to cover filing fees and costs. For a more detailed statement of the courts duties upon receipt of a prisoners affidavit, see the form summary for the court order, CV- 441. If the prisoner is not alleging to be in imminent danger of physical injury, a separate petition (CV-438) and court order (CV-439) 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: 01/08/02 Page 2 <<<<<<<<<********>>>>>>>>>>>>> 3 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY For Official Use Please print or type Prisoners Petition for Waiver of Prepayment of Fees/Costs Based on Imminent Danger -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 those costs because of poverty. 2. I am in imminent danger of serious physical harm. Attached is a statement, under oath, detailing the facts concerning the immediacy of the danger and the type of physical harm claimed. (Be specific as to dates, times, places, participants, verbal or other claims made, what the danger is, and why information should be believed.) 3. I have attached and incorporated into this affidavit: A copy of my pleading(s) in this matter. [If this proceeding is related to prison or jail conditions]: Written documentation of exhaustion of all available administrative remedies concerning the subject of these pleadings, 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. 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 received): 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:.....................$ other: ......................................$ 8. I have the
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