UNITED STATES DISTRICT AND BANKRUPTCY COURTS FOR THE DISTRICT OF COLUMBIA CONSENT TO COLLECTION OF FEES FROM TRUST ACCOUNT Re: ____________________________________ v. ___________________________________ Civil Action No. __________________________ I, ________________________________________, Reg. No. _____________________, hereby consent for the appropriate prison official to withhold from my prison account and to pay the U.S. District Court an initial fee of 20 percent of the greater of: (a) the average monthly deposits to my account for the six-month period immediately preceding the filing of my complaint; or the average monthly balance in my account for the six-month period immediately preceding the filing of my complaint. (b) I further consent for the appropriate prison officials to collect from my account on a continuing basis each month, an amount equal to 20 percent of each month's income. Each time the amount in the account reaches $10.00, the Trust Officer shall forward the interim payment to the Clerk's Office, U.S. District Court, until such time as the $400.00 filing fee is paid in full. If appropriate, I will execute the institution consent form where I am housed, which will permit the staff to withdraw the amount ordered by this court as payment for the filing fee each month until the $400.00 filing fee is paid in full. By executing this document, I also authorize collection, on a continuing basis, of any costs imposed by the District Court. ____________________________________ Signature of Plaintiff __________________ Date American LegalNet, Inc. www.FormsWorkFlow.com