UNITED STATES COURT OF APPEALS FOR THE SECOND CIRCUIT PRISONER AUTHORIZATION FORM THIS SECTION MUST BE COMPLETED BY APPELLANT CASE TITLE: USCA DOCKET NUMBER: DISTRICT: DISTRICT/AGENCY NUMBER: APPELLANT: COUNSEL'S NAME: COUNSEL'S PHONE: Pursuant to 28 USC § 1915(b), I, request and authorize the institution holding me in custody to send to the Clerk of the United States Court of Appeals for the Second Circuit certified copies of my prison trust fund account statements or the institutional equivalent for the past six months. I further request and authorize the institution holding me in custody to calculate the amounts specified by the statutes, to deduct those amounts from my prison trust fund account, or institutional equivalent, and to disburse those amounts to the United States District Court for the ___________________________ . This authorization is furnished in connection with the above numbered and entitled case and shall apply to any institution into whose custody I may be transferred. I UNDERSTAND THAT THE COURT OF APPEALS FILING FEE OF $505 WILL BE PAID IN ITS ENTIRETY, IN MONTHLY INSTALLMENTS, BY AUTOMATIC DEDUCTIONS FROM MY PRISONER TRUST FUND ACCOUNT EVEN IF MY APPEAL IS DENIED OR DISMISSED. THE COLLECTED FUNDS WILL BE FORWARDED AS PAYMENT UNDER § 1915 TO THE UNITED STATES DISTRICT COURT FOR THE _________________________. ________________________ Signature of Appellant ___________ Date _________________________ Print Name Rev. February 25, 2014 American LegalNet, Inc. www.FormsWorkFlow.com