C.A. No. AUTHORIZATION FOR WITHDRAWAL OF FUNDS NOTICE TO PRISONER: You are directed to complete the following form. Part A of the form must be returned to the Clerk. Part B of the completed form shall be returned to the prison official in charge of the prisoner account. PART A I, (Name of Prisoner and Registered Number if applicable) authorize the Clerk of the Court to obtain, from the agency having custody over me, information about my institutional account, including balances, deposits, and withdrawals. The Clerk may obtain such information until the fee and any other payments owed the Court are paid. I also authorize the agency having custody over me to withdraw funds from my account and forward payments to the appropriate Clerk of Court in accordance with 28 U.S.C. 2471915. Signature of Prisoner Date ------------------------------------------------------------------------------------------------------------ PART B I, (Name of Prisoner and Registered Number if applicable) authorize the Clerk of the Court to obtain, from the agency having custody over me, information about my institutional account, including balances, deposits, and withdrawals. The Clerk may obtain such information until the fee and any other payments owed the Court are paid. I also authorize the agency having custody over me to withdraw funds from my account and forward payments to the appropriate Clerk of Court in accordance with 28 U.S.C. 2471915. Signature of Prisoner Date (Rev. 01/31/08) American LegalNet, Inc. www.FormsWorkFlow.com