IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF FLORIDA DIVISION , Inmate # Plaintiff/Petitioner . vs. CASE NO: , , . Defendant(s)/Respondent(s). / PRISONER CONSENT FORM AND FINANCIAL CERTIFICATE I, , plaintiff/pe titioner in the ab ove-entitled action , understand that: 1. If I subm it a petition for writ of habeas corpus in this court, the filing fee is $5.00. I must pay such fee if my current prison ac cou nt balance, m y average acc ount balance, or the average of m y m onthly deposits is $25.00 or m ore. I m ust re quest an authorized official to com plete the attached Financial Certificate and I must attach a print-out reflecting all transactions in my inmate bank account for the fu ll six (6) m onth period of tim e prec eding the filing of this com plaint. [See p arag raph 2(a)]. 2. If I submit a civil rights complaint or other civil action, the filing fee is $350.00. If my current account balance is m ore th an $ 400 .00, I will not qualify for in form a pauperis status. I must pay the full $350.00 filing fee before the Court will consider the m erits of m y com plaint. I m ust re que st an authorized official to com plete the attached Financial Certificate and I must attach a prin t-out reflecting all transactions in my inmate bank acc oun t for the full six (6) m onth period of tim e pre ced ing the filing of this com plaint. (a) If I have not been incarcerated at my current institution for six months, I must obtain an account statement from each facility at which I have been confined during the relevant six m onth period of time. Failure to subm it the req uired account sta tem ents m ay re sult in the denial of this in forma pauperis application. (b) Pursuant to the Prison Litigation Reform Act of 1995, 28 U.S.C. § 1915 (as amended), even if I am granted leave to proceed in form a pauperis, I must pay the entire $350.00 filing fee in full. I AM OBLIGATED TO PAY THE ENTIRE $350.00 FILING FEE REGARDLESS OF THE DIS PO SIT ION OF TH IS CAS E (including dismissal). American LegalNet, Inc. www.FormsWorkFlow.com (c) If I am allowed to proceed in form a pauperis, I may still be required to submit an initial partial filing fee. 28 U .S.C . § 1915(b )(1). M y failure to s ubm it an initial partial filing fe e, if ass ess ed, m ay result in the dismissal of this case and the inability to proceed in form a pauperis in the future. (d) The officials at the institution at which I am presently confined or any institution to which I may be transferred are hereby authorized to mak e additional monthly payments from m y account until the balance of the $350.00 filing fee is paid. These additional monthly payments will be up to 20% of all the preceding m onth's deposits in m y account. Ins titution officials sha ll subm it these m onth ly paym ents directly to the Court whenever the funds in my account exceed $10.00. I recognize m y responsibility to alert officials at any institution to which I m ay be transferred in the future of my obligation to pay the full amount of the filing fee. I acknowledge that the Court m ay, from time to tim e, require me to provide additional financial records or acc oun t statem ents . SIGNATURE OF PLAINTIFF DATE PRINTED NAME OF PLAINTIFF INMATE NUM BER ** It is the inmate's responsibility to obtain the required print-out(s) from each institution at which he or she may have been confined during the preceding six months and provide them to the official completing this form . ************************************************* FINANCIAL CERTIFICATE (T o be com plete by Autho rized Penal O ffic ial) A P RIN TOUT OF A LL TR AN SACT IONS IN T HE INM AT E'S PRISON ACCOU NT FOR THE PRECEDING SIX (6) MONT HS MU ST BE ATTACHED. 1. Current Account Balance: 2. Average Monthly Balance for preceding 6 months: 3. Average Monthly Deposits for preceding 6 months: I hereby certify that, as of this date, the above information for the prison accou nt of the inm ate nam ed ab ove is correct. SIG NAT UR E O F AU TH OR IZED OF FICIAL DATE PLEASE COMPLETE THIS FORM IN INK, IN A COLOR OTHER THAN BLACK. Revised 04/06 2 American LegalNet, Inc. www.FormsWorkFlow.com