IMPOUNDED - CONFIDENTIAL COMMONWEALTH OF MASSACHUSETTS Court NO. INFORMATION FOR THE INMATE/APPLICANT: You have requested that the Court waive the filing fees and (normal) costs and allow you to proceed as an indigent plaintiff. You are required to provide the court with information about your finances so that the court can determine whether you are unable to pay the fee or to make partial payments. You are required to sign this affidavit form under the penalties of perjury. This includes a statement that no action has been taken to hide assets. The court can dismiss the complaint if it finds that the claim of indigency is untrue. In addition, the court may impose costs on an inmate who intentionally files an affidavit that contains false information or that omits material information. You are also subject to loss of up to 60 days of good time earned or to be earned under G. L. c. 127, § 129C ( for blood donation) or under c. 127, § 129D (for work, education or rehabilitation programs) if the court finds that the affidavit is frivolous and filed in bad faith in order to abuse the judicial process. See G. L. c. 261, § 29. , Plaintiff(s) , Defendant(s) v. INMATE'S AFFIDAVIT OF INDIGENCY AND REQUEST FOR WAIVER OF NORMAL FEES AND COSTS IN COMPLIANCE WITH GENERAL LAWS c. 261, § 29 Pursuant to General Laws c. 261, § 29, the applicant, the following information is true. , swears (or affirms) that (NAME) SOCIAL SECURITY #: DATE OF BIRTH: INMATE IDENTIFICATION #: CORRECTIONAL FACILITY: American LegalNet, Inc. www.FormsWorkflow.com ASSETS: CASH: MONIES IN BANK ACCOUNTS: INMATE CANTEEN ACCOUNT: OTHER INSTITUTIONAL ACCOUNT: NON-PRISON ACCOUNT(S): REAL ESTATE: OTHER INVESTMENTS: ACCESSIBLE ASSETS OF A SPOUSE: INCOME: LAST SIX MONTHS' INCOME: INCOME EXPECTED IN NEXT SIX MONTHS: LIABILITIES (for example, any debts you owe, including Victim/Witness fees, restitution fees, child support, other court-imposed costs, and costs assessed for incarceration and pre-release programs): MONTHLY EXPENSES: NECESSARY CANTEEN PURCHASES (for example, stamps, envelopes, soap, toothpaste and other toiletries, medications and clothing): OTHER EXPENSES: American LegalNet, Inc. www.FormsWorkflow.com I state under penalties of perjury that the statements made in this affidavit are true, that I have not omitted any assets that are available to me to pay filing fees or court costs, that I have not transferred any assets to avoid payment of filing fees and costs, and that I have not taken any action nor has any action been taken on my behalf relative to any assets in order to avoid having such assets used for payment of filing fees and costs. Signature of applicant: _____________________________________________ DATE: ALL INFORMATION CONTAINED HEREIN IS CONFIDENTIAL. EXCEPT BY SPECIAL ORDER OF A COURT, IT SHALL NOT BE DISCLOSED TO ANYONE OTHER THAN AUTHORIZED COURT PERSONNEL, PARTIES TO THIS LITIGATION OR THEIR COUNSEL, AND AN AUTHORIZED (IN WRITING) REPRESENTATIVE OF THE APPLICANT. American LegalNet, Inc. www.FormsWorkflow.com