IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA Name of Plaintiff(s) v. : : : : : : : : : : : : : : : : : : Civil Case No. Judge (Number and Judge to be assigned by court) Name of Defendant(s) APPLICATION TO PROCEED IN FORMA PAUPERIS PLEASE READ CAREFULLY AND FULLY COMPLETE EACH SECTION. l. I am willing to pursue my claims in this action under the new provisions of The Prison Litigation Reform Act, understanding that pursuing my claim requires payment of a partial filing fee and deduction of sums from my prison account when funds exist until the filing fee of $350.00 has been paid in full. 2. I have enclosed an executed Authorization form which authorizes the Institution holding me in custody to transmit to the Clerk a certified copy of my trust account for the past six (6) months as well as payments from the account in the amounts specified by 28 U.S.C. §1915(b). 3. Have you, prior to the filing of the complaint in this action and while a prisoner as that term is defined in 28 U.S.C. § 1915(h), brought 3 or more actions or appeals in a court of the United States that were dismissed as frivolous, malicious, or for failure to state a claim upon which relief may be granted? Yes No American LegalNet, Inc. www.FormsWorkflow.com (a) If the answer is "yes," are you now seeking relief because you are under imminent danger of serious physical injury? Yes No (b) Please explain in detail why you are under imminent danger of serious physical injury: 4. (a) (b) Are you presently employed at the Institution? If yes, what is your monthly compensation? Yes No $ 5. Do you own any cash or other property; have a bank account; or receive money from any source? Yes No If the answer is "yes" to any of the above, describe each source and the amount involved. I certify under penalty of perjury that the foregoing is true and correct. Executed on (Date) (Signature of Plaintiff) This certification is executed pursuant to Title 28, United States Code, Section 1746. 2 American LegalNet, Inc. www.FormsWorkflow.com