UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT PRISONER'S APPLICATION TO PROCEED IN FORMA PAUPERIS IN A CIVIL RIGHTS ACTION ATTACH THIS FORM TO YOUR COMPLAINT : PRISONER [Your name] : NO: cv ( ) Plaintiff, : [Leave blank for Clerk] : vs. : : : : : [People you are suing] : Defendant(s): I, , [your name] state that, because of my poverty, I am unable to pay the filing fee for the above-captioned lawsuit at the time that I file my complaint. I therefore request permission to file my complaint without pre-payment of the filing fee and to proceed in forma pauperis (as a poor person). I understand that I cannot file for free. I realize that even if the Court allows me to proceed in forma pauperis I will have to pay the full filing fee of $350 through installments deducted from my inmate trust fund. I also understand that the Department of Correction Inmate Trust Fund will continue to deduct money from my 2 Revised 3/8/18 inmate trust fund to pay the filing fee to the Court even if my lawsuit is dismissed. I also understand that I must support my claim of poverty by truthfully answering all of the following questions and by obtaining a signed certification of the balance on my inmate trust fund from the DOC Inmate Trust Fund or my prison counselor. I realize that I may be prosecuted for perjury if I lie on this application, and that perjury is punishable by imprisonment for up to five years and/or a fine of $250,000 (18 U.S.C. 247247 1621, 3571). WARNING: You MUST complete EVERY section or your application will be denied. Answer every question truthfully and accurately. 1.Full Name: 2.Inmate Number: 3.Correctional Institution: 4.Are you currently employed? (Yes or No) 5.If you are currently employed, state your job title and the amount you get paideach month: Job: Monthly wages: $ 6.Within the past twelve (12) months, how much money have you received from a.Employment: Type $ b.Rent someone paid you:$ c.Interest on savings:$ d.Dividends on investments: $ e.Pension, annuity, or life insurance: $ d.Gifts or inheritances:$ e.Other sources: Type $ 3 Revised 3/8/18 7.How much money do you have in cash, or in checking or savings accounts, includingyour inmate trust account? [If none, $ 8.What is the total value of property you own excluding ordinary household furnishingsand clothing, but including automobiles, real estate, stocks, bonds, and notes?[If none, $ 9.How much money do you contribute each month to the support of family membersor other individuals? Provide the name of each person you support and therelationship between you (e.g., husband, wife, domestic partner, child, orgrandparent). [If you need more space, attach an additional page.] a.Name & Relationship:$ b.Name & Relationship:$ c.Name & Relationship: $ DECLARATION UNDER PENALTY OF PERJURY WARNING: You MUST sign this section or your application for IFP status will be denied. I, , the applicant, declare under penalty of perjury that the information I have provided in this application is true and correct. Signed: Dated: , 20 WARNING: You have not finished. You MUST complete the next section. 4 Revised 3/8/18 PRISONER AUTHORIZATION WARNING: You MUST complete and sign this section and then show this page to the Inmate Trust Fund Department or your prison counselor so that they can sign the next section. Your name: Your inmate number: DOC facility where you are detained: Case Number [leave blank for Clerk]: Filing Date [leave blank for Clerk]: I, ,the applicant, understand that even if my request for In Forma Pauperis status is granted, Congress has said that I must pay the full filing fee of $350, which will be deducted in installments from my inmate trust fund. I further understand that the deductions from my inmate trust fund will continue until the full fee is paid, even if my case is dismissed before then. I authorize the Department of Correction Inmate Trust Fund to: (1) certify on the next page of this application the current and average balance over the last six months for my inmate trust fund; (2) send the Court copies of my trust fund statement for the past six months; (3) obtain funds to cover the $350 filing fee by deducting installment payments from my inmate trust fund based on the average of deposits to or balance in my inmate trust fund, in accordance with 28 U.S.C. Section 1915; (4) send the $350 payment for the filing fee to the Court. Signed: [Your signature] Date: , 20 WARNING: You have not finished. You MUST show this page to the Inmate Trust Fund Department or your prison counselor so that they can sign the next section. Do NOT send this application to the Court without the signature of the Inmate Trust Fund Department or your prison counselor on the next page. 5 Revised 3/8/18 CERTIFICATION OF INMATE ACCOUNT BALANCE WARNING: You MUST show this application to the Inmate Trust Fund Department or your prison counselor so that they can read page 4 and sign this section. Your name: Your inmate number: DOC facility where you are detained: I, , counselor / employee of the Connecticut Department of Correction Inmate Trust Fund, certify that the applicant named herein has the sum of $ on account. I further certify that, according to the records of the institution, the average balance for the last six months was $ and the average monthly deposits during the same period were $ . A certified copy of the applicant's trust fund statement for the last six (6) months is attached. Signed: (Inmate Trust Fund Officer or Prison Counselor) Name & Rank: Date: , 20 6 Revised 3/8/18 CHECKLIST FOR IFP APPLICATION NOTE: Before you send this application to the Court you MUST: Sign the Declaration under Penalty of Perjury on p. 3 Sign the Prisoner Authorization on p. 4 Show the application to the Inmate Trust Fund Department or your prison counselor and have them sign p. 5 Answer every question truthfully and accurately Attach trust fund statement for the last six (6) months (ledger sheet) When the Inmate Trust Fund Department or your counselor has signed page 5, attach this form to your complaint and submit to the Court.