PLRA Application

06/01/2018 SCC Page 1 of 3 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: 1. Identify the reason you are currently incarcerated or detained: [ ] Incarcerated on a criminal conviction [ ] Detained pending criminal trial or sentencing [ ] Detained for immigration proceedings [ ] Civil commitment due to mental disease or defect or as a sexually dangerous person [ ] Other (describe): 2. 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. The Prison Litigation Reform Act (PLRA), 28 U.S.C. 247 1915(b), requires that any person incarcerated or detained in any facility, who is accused of, convicted of, sentenced for, or adjudicated delinquent for, violations of criminal law or the terms and conditions of parole, probation, pretrial release, or diversionary program who is unable to pay the filing fee on appeal from a civil action apply to pay the filing fee in installments from the prisoner222s trust account. The PLRA further provides that if the inmate has, while incarcerated, filed three or more prior actions or appeals which were dismissed by a feder al court as frivolous, malicious, or for failure to state a claim, the inmate is required to prepay the full fee unless under imminent danger of serious physical injury. 28 U.S.C. 247 1915(g). American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 b. If the answer is yes, state the facts in support of any claim that you are under imminent danger of serious physical injury. 3. 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. 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. 4. 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. 5. 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. 6. 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. 7. List the persons who are dependent upon you for support and state your relationship to those persons. 8. If you are incarcerated or detained on criminal charges, you must 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. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 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: American LegalNet, Inc. www.FormsWorkFlow.com