UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT OFFICE OF THE CLERK 1100 East Main Street, Suite 501 Richmond, Virginia 23219-3517 www.ca4.uscourts.gov Patricia S. Connor Clerk Telephone 804-916-2700 ____________________________ PRISONER TRUST ACCOUNT STATEMENT ____________________________ No. ___________, _________________v.____________________________ ______________________________ (lower court case no.) TO: Trust Officer FROM: Clerk, U.S. Court of Appeals for the Fourth Circuit RE: ___________________________________ (Prisoner Name/Reg.No.) Under the Prison Litigation Reform Act, a prisoner appealing a civil judgment must obtain from the trust officer of each institution in which the prisoner was confined during the preceding six months a certified copy of the prisoner's trust account statement for the six months prior to filing of the appeal. Please complete this form, attach the supporting ledger sheets, and return these documents to the prisoner for mailing to the Court of Appeals within 7 days. Date of Filing Notice of Appeal in Court of Appeals Balance at Time of Filing Notice of Appeal Average Monthly Deposits during 6 months prior to Filing Notice of Appeal Average Monthly Balance during 6 months prior to Filing Notice of Appeal I certify that the above information accurately states the deposits and balances in applicant's trust account for the period shown and that the attached ledger sheets are true copies of account records maintained in the ordinary course of business. Signature ____________________ Date _____________________ Print Name & Title: ______________________________________ 09/21/2011 SCC American LegalNet, Inc. www.FormsWorkFlow.com