//201 SCC [insert name of court] ) ) v. ) Case No. ) ) DECLARATION OF INMATE FILING I am an inmate confined in an institution. On [insert date], I deposited the [insert title of document: for example "notice of appeal" or "petition for rehearing/rehearing en banc"] in this case in the institution's internal mail system. First-class postage was 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: Print your name here: Date Signed: [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. App. P. 4(c)(1) or Fed. R. App. P. 25(a)(2)().] American LegalNet, Inc. www.FormsWorkFlow.com