UNITED STATES DISTRICT COURT Revised 05/01 WDNYWESTERN DISTRICT OF NEW YORK IMPORTANT FEE INFORMATION If you do not have sufficient funds to pay the full filing fee of $150.00, you may request permission toproceed in forma pauperis under 28 U.S.C. 1915. Because you are incarcerated, the statute requiresyou to pay the filing fee, but it permits you to pay it in installments over time. You may file your casewithout paying for the filing fee at the time of filing by sending to the Court with your complaint a fully-completed and signed Request to Proceed in Forma Pauperis and a signed Authorization form by which you authorize your Correctional Facility to remove the statutory amounts from your inmate account overtime. When your case is opened, the Court will send a copy of your Authorization to your CorrectionalFacility, which will then begin collecting the fee by removing from your inmate account an initial partialfiling fee of 20 percent of the greater of: 1) the average monthly deposits to your prison account for the past six months; or 2) the average monthly balance in your prison account for the prior six month period. Thereafter, your Correctional Facility will take payments from your account pursuant to statute until theentire filing fee is paid. See 28 U.S.C. 1915(b) for the calculations applicable to this fee deductionfrom your account. CAUTION: YOUR OBLIGATION TO PAY THE FILING F E E CONTINUES UNTIL YOUR FILING FEE IS PAID, EVEN IF YOUR COMPLAINT HAS ALREADY BEEN DISMISSED BY THE COURT. To obtain in forma pauperis status, you must: 1) Fill out a Motion to Proceed In Forma Pauperis form. You must respond to all of the questions, and have the appropriate prison official fill out and sign the Prison Certification Section.. 2) Fill out and sign the attached Authorization form by which you authorize the institution in which you are incarcerated to provide the court with a certified copy of your trust fund account statement for the six month period immediately preceding the filing of the complaint, and to calculate and pay the filing fee as directed by the statute. 3) Return both the completed Motion to Proceed In Forma Pauperis and completed Authorization form to the Clerk of the Court, United States District Court for the Western District of New York. 28 U.S.C. 1915(g) Strike Information If you have three or more prior cases or appeals dismissed as frivolous, malicious or for failure to state a claim upon which relief may be granted (such dismissals are called "strikes"), you must pay the filing fee in full before another complaint or appeal will be accepted for filing, unlessyou are in imminent danger of serious physical injury. See 28 U.S.C. 1915(g). >>>> 2Revised 05/01 WDNY AUTHORIZATION PRISONERS CIVIL ACTION FILING FEE WESTERN DISTRICT OF NEW YORKI, (print name) , request andauthorize the agency holding me in custody, to send to the Clerk of the United States DistrictCourt, Western District of New York, a certified copy of the statement for the past six monthsof my trust fund account (or institutional equivalent) at the institution where I am incarcerated.I further request and authorize the agency holding me in custody to calculate and disbursefunds from my trust account (or institutional equivalent) in the amounts specified by 28U.S.C. 1915 (b), to deduct those amounts from my prison trust account (or institutionalequivalent), and to disburse those amounts from my account to the United States DistrictCourt for the Western District of New York. This Authorization shall apply to any other agency into whose custody I may be transferred, and to any other district court to which my case may be transferred and by which my poor person application may be decided.This Authorization is furnished in connection with the commencement of a federal court civilaction, and I understand that I must pay the total amount of the filing fee, which is $150.00.I understand that by signing this authorization, the entire filing fee of$150.00 will be paid to the court in installments by automatic deductionsfrom my prison trust fund account even if my case is dismissed before theentire amount of the fee has been deducted from my account.Dated: , 20 Signature of prisoner Printed name of prisoner Inmate number of prisoner