UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA PRISONER TRUST ACCOUNT REPORT Name:_______________________________Registration #:_______________________________ Please submit this to the trust officer of every institution in which you have been confined during the preceding six months. Submit the completed forms and supporting ledger sheets to the Court. *************************************************************** Trust Officer To: From: Clerk, U.S. District Court for the District of Columbia Under the Prison Litigation Reform Act (PLRA), a prisoner filing a civil action must obtain from the trust officer of each institution in which the prisoner was confined during the preceding six months a certified copy of the prisoner's trust account statement for the six months prior to filing of the action. 28 U.S.C. ' 1915(a)(2). Please complete this form, attach the supporting ledger sheets, and return these documents to the prisoner. BALANCE at time of filing of the action: AVERAGE MONTHLY DEPOSITS during the six months prior to filing of the action: AVERAGE MONTHLY BALANCE during the six months prior to filing of the action: ________________________________ ________________________________ ________________________________ I certify that the above information accurately states the deposits and balances in applicant's trust fund account for the period shown and that the attached ledger sheets are true copies of account records maintained in the ordinary course of business. Date: ______________________ Authorized Signature: ____________________________________________________________ Title: _________________________________________________________________________ 2000 � American LegalNet, Inc.