UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE ___________________________ Name of Plaintiff(s)/Petitioner(s) v. ___________________________ Name of Defendant(s) Civil Case No. PRISONER LITIGATION REFORM ACT CONSENT FORM (CONSENT TO COLLECTION OF FEES FROM INMATE TRUST ACCOUNT) I, ____________________________, ID No. __________________, agree that upon entry of a court order approving my application to proceed in forma pauperis, the appropriate prison officials shall collect from my prison account, and pay to the Clerk of Court for the United States District Court for the District of New Hampshire, an initial payment of twenty percent of the greater of: (a) the average monthly deposits to my account for the six month period immediately preceding the filing of my motion/application to proceed in forma pauperis; or (b) the average monthly balance in my account for the six month period immediately preceding the filing of my motion/application to proceed in forma pauperis. I further agree that, on a monthly basis, appropriate prison officials may deduct 20% of each preceding month's income credited to my inmate account, and transfer those monies from my account to the Clerk of Court, when the amount in the account exceeds $10.00. Specifically, I authorize inmate accounts to retain 20% of all income deposited into my inmate account, and to submit that amount to the United States District Court for the District of New Hampshire, until the applicable filing fee is paid in full. I also agree that this authorization to deduct monies from my inmate account as set forth above shall apply to any other agency into whose custody I may be transferred. I understand that in the event I am released from custody prior to making full payment of the filing fee, I am still required to pay the remainder of the unpaid fee. By submitting this consent form, I understand that it is not necessary to submit an inmate slip to authorize payment and, if the motion in forma pauperis is granted, that the court will contact inmate accounts directly to request payment on my behalf. I also understand that by signing this consent form, I am making an irrevocable decision to have the filing fees deducted from my inmate account and that I may not subsequently request that inmate accounts decline to make the initial payment or any subsequent payments as set-forth above. Print Full Name and Inmate Number: ________________________________________ Date: _____________________________________ Plaintiff/Inmate Signature USDCNH-14A (Rev. 5/12) American LegalNet, Inc. www.FormsWorkFlow.com