Form 4170 (12/18) Declaration of Inmate Filing [insert name of court; for example, United States District Court for the District of Minnesota] In re [insert debtor name] , Plaintiff v. Case No. , Defendant I am an inmate confined in an institution. Today, [insert date], I am depositing the [insert title of document; for example, 223notice of appeal224] in this case in the institution222s internal mail system. First-class postage is being prepaid either by me or by the institution on my behalf. I declare under penalty of perjury that the foregoing is true and correct (see 28 U.S.C. 247 1746; 18 U.S.C. 247 1621). Sign your name here Signed on [insert date] [Note to inmate filers: If your institution has a system designed for legal mail, you must use that system in order to receive the timing benefit of Fed. R. Bankr. P. 8002(c)(1) or Fed. R. Bankr. P. 8011(a)(2)(C).] American LegalNet, Inc. www.FormsWorkFlow.com