UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT 1100 East Main Street, Suite 501 Richmond, Virginia 23219-3517 www.ca4.uscourts.gov ____________________________ CONSENT TO COLLECTION OF FEES FROM TRUST ACCOUNT FOR ORIGINAL PROCEEDINGS ____________________________ No. _________, _________________v.____________________________ _____________________________ (lower court case no.) FEE AMOUNT: $500 PAYABLE TO: Clerk, U.S. Court of Appeals I, _________________________, # _________________________, hereby consent for the appropriate prison officials to assess and, when funds exist, collect an initial partial filing fee of 20 percent of the greater of: (a) the average monthly deposits to my account for the six-month period immediately preceding the filing of my petition; or (b) the average monthly balance in my account for the six-month period immediately preceding the filing of my petition. I further consent for the appropriate prison officials to collect: monthly payments of 20 percent of my preceding month's income and forward the payments to the Clerk, U.S. Court of Appeals, each time the amount in the account exceeds $10 until the filing fee has been paid in full. I understand that by signing this consent I agree to payment of the full filing fee from my trust account regardless of whether I later choose to dismiss my petition or the court decides my petition before the entire amount has been paid. I understand that once consent to the collection of fees has been given it cannot be withdrawn. Signature _____________________ Date ____________________ American LegalNet, Inc. www.FormsWorkFlow.com 06/03/2014 SCC