Prison Account Statement Form

C.A. No. CERTIFICATION OF PRISON ACCOUNT STATEMENT NOTICE TO PRISONER: You must submit to this Court a certified copy of your prison trust fund account statement (or institutional equivalent) for each institution in which you have been confined for the six-month period immediately preceding the date of this application. 28 U.S.C. 2471915(a)(2). If you were housed in more than one institution in the past 6 months, a copy of the certification must be completed by each institution. The following certification from an authorized officer of your institution(s) must accompany the account statement(s): 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 in forma pauperis . 28 U.S.C. 247 1915(b)(2). Pursuant to that statute, once an initial partial fee is paid, the prison official in charge of the prisoner's account must forward monthly payments of 20% of the income credited to the prisoner's account during the preceding month, each time the amount in the account exceeds $10, until the entire filing and/or docketing fee has been paid. I certify that the attached trust fund account statement (or institutional equivalent) is true and correct. Authorized Officer of Institution (Rev. 5/00) American LegalNet, Inc. www.FormsWorkFlow.com