COMMONWEALTH OF MASSACHUSETTS Court __________________________ Case number: _________________________________ Civil Action Case Name: ______________________________________, Plaintiff(s) v. ______________________________________, Defendant(s) NOTICE OF WAIVER OF COURT COSTS AND REQUEST FOR PAYMENT TO BE WITHDRAWN FROM ACCOUNT PURSUANT TO G. L. c. 261, § 29 The prisoner/plaintiff in the above-captioned action has filed a motion to waive the filing fee and court costs (normal) and to proceed in forma pauperis. After reviewing the affidavit of indigency and the statement of inmate account provided by the correctional facility, the court hereby orders: _____ The plaintiff is incapable of paying the filing fee and may proceed in forma pauperis. _____ The plaintiff is ordered to pay a lump-sum partial payment of $ ___________ in order to proceed. The court further finds that requiring additional installment payments would create an undue administrative burden for the court. _____ The plaintiff has sufficient funds such that an installment payment schedule would not be an administrative burden for the court. The plaintiff is ordered to pay the filing fee of $ ______ in installments as follows: $ _______ for the first installment payment, which represents 20% of the preceding six months average balance in the prisoner’s account. (Note: the balance in the account must be large enough so that the 20% payment is at least $10. See G. L. c. 261, § 29.) AND: in subsequent months, monthly payments representing 10% of the average monthly balance remaining in the prison’s account until the fee is paid. (Note: the balance in the account must be large enough so that each 10% payment is at least $10. See G. L. c. 261, § 29.) The prisoner’s name and case number must be noted on each remittance. American LegalNet, Inc. www.FormsWorkFlow.com By the Court ( ) ____________________________ Clerk or Assistant Clerk Dated: _________________________ The undersigned prisoner/plaintiff authorizes the Commission of Correction or the County Sheriff AND the Superintendent of the facility where he or she is incarcerated to withdraw the payment(s) as ordered above and send it to the court. If installment payments are ordered, this authorization remains in effect for each monthly payment unless the undersigned revokes authorization in writing. This authorization is valid in any state or county correctional facility to which the prisoner may be transferred. __________________________________ Prisoner/Plaintiff Dated: _____________________________ ALL PRISONERS MUST SEND A COPY OF THIS FORM TO THE SUPERINTENDENT OF THE FACILITY WHERE THEY ARE INCARCERATED AND TO THE COMMISSIONER OF CORRECTION (IF YOU ARE IN A STATE FACILITY) OR TO THE COUNTY SHERIFF (IF YOU ARE IN A COUNTY FACILITY). American LegalNet, Inc. www.FormsWorkFlow.com