IN THE SUPREME COURT OF THE STATE OF ALASKA APPLICATION FOR EXEMPTION FROM FILING FEE For Use in Prisoner Civil Appeals Against the State of Alaska Under AS 9.19.010 - 100 Print Form Instructions: Complete only if Appellant seeks a filing fee exemption under AS 9.19.010. If a filing fee exemption is sought, this form must be completed, and the documents listed in Item 3 must be attached. A waiver of cost bond must be sought by separate motion. 1. Appellant’s Name: 2. Appellant’s Affidavit: a. I am a prisoner as defined in AS 33.30.901. b. My complete financial situation, including my income, assets and court ordered payments is accurately and fully set out in the attached Supreme Court/Court of Appeals Financial Statement Form. c. The following circumstances prevent me from paying a full filing fee: (Continue on this explanation Continue back if necessary.) d. Nature of the action or appeal (Include specific facts that, if proved, would entitle Appellant to a reversal on appeal): Continue back if necessary.) (Continue on this explanation 3. Attached documents: a. Supreme Court/Court of Appeals Financial Statement. b. Certified copy of Appellant account statement from the Department of Corrections for the six-month period preceding the date of this application. 4. Oath: I declare under oath that all statements made in this application are true. ___________________________________ Date ________________________________________________________ Appellant’s Signature Subscribed and sworn to or affirmed before me on _________________________, 19_____ in _________________________ Alaska. _______________________________________________________ (SEAL) Notary Public My commission expires: ___________________________________ Proof of Service: I certify that on ___________________________ a copy of this application and attachments was mailed to ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Signature: _______________________________________________ SCT - 919app(rev.1/98) American LegalNet, Inc. www.USCourtForms.com Continuation of Application for Exemption from Filing Fee 2. c. The following circumstances prevent me from paying a full filing fee (continued): 2. d. Nature of the action of appeal (continued): SCT - 919app - 2 (rev. 1/98) American LegalNet, Inc. www.USCourtForms.com