Form 6A Supplemental In Forma Pauperis Form For Prisoners
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Form 6A Supplemental In Forma Pauperis Form For Prisoners Form. This is a Official Federal Forms form and can be use in US Court Of Appeals For The Federal Circuit.
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FORM 6A. Supplemental in Forma Pauperis Form for Prisoners
SUPPLEMENTAL IN FORMA PAUPERIS FORM FOR PRISONERS
, request and authorize the agency holding me in custody,
to send to the Clerk of the United States Court of Appeals for the Federal Circuit a certified copy
of the statement for the past six months of my trust fund account (or institutional equivalent) at
the institution where I am incarcerated. I further request and authorize the agency holding me in
custody to calculate and disburse funds from my trust fund account (or institutional equivalent)
in the amounts specified by 28 U.S.C. § 1915(b). This authorization is furnished in connection
with an appeal, and I understand that the total appellate filing fees for which I am obligated are
$450 or $455. I also understand that these fees will be debited from my account regardless of the
outcome of my appeal. This authorization shall apply to any other agency into whose custody I
may be transferred.
You must sign and date above. You must also complete the following Disclosure and sign and date
the Declaration Under Penalty of Perjury below.
DISCLOSURE OF PRIOR FEDERAL ACTIONS
If you are presently incarcerated, have you ever before brought an action or appeal in a federal
court while you were incarcerated or detained?
If so, how many times?
Were any of the actions or appeals dismissed because they were frivolous, malicious, or failed to
state a claim upon which relief may be granted?
If so, how many of them?
DECLARATION UNDER PENALTY OF PERJURY
I declare under penalty of perjury, under the laws of the United States, that the foregoing is true
Effective May 1, 2008
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