I THE UNITED STATES DISTRICT COURT N FOR THE WESTERN DISTRICT OF PENNSYLVANIA VS. MOTION AND DECLARATION I SUPPORT OF MOTION TO PROCEED N I FORMA PAUPEIUS N am the plaintiff in the above entitled case. support of my motion for leave to proceed in forma pauperis, I state that because of my poverty I am unable .to pay the initial costs of said proceeding or to give security therefore and that I believe I am entitled to redress. In support of this motion, I declare the following responses are true. 1 , 1. If you are receiving prison wages, state the amount: 2 . 1f you received within the past twelve months any money form any source, explain, and state The amount: 3. State the amount of money you have in a checking, savings, or prison account: 4. Identify and state the value of any real estate, stocks, bonds, notes, automobiles, o r 0thValuable propem (excluding ordinary household furnishings and clothing) which you own: 5. List the persons who are dependent upon you for support; state relationship to those And indicate how much you contribute toward their support: I declare under penalty of perjury that the foregoing is true and correct. SIGNED THIS DAY OF Plaintiff's signature , 20-. American LegalNet, Inc. www.FormsWorkFlow.com TO BE COMPLETED BY RECORDS OFFICER OF PRISON 1. T h e plaintiff presently has the sum of (Name of prison) Attached is a copy of the plaintiffs institutional account indicating deposits and withdrawals during the preceding one year period or (Indicate period covered by Account) I cannot furnish the court with a copy of the plaintiffs institutional account indicating income and withdrawals because on account at 2. The plaintiff has the following securities and other assets: (include any information you have regarding outside accounts, sources of income): 3 . Other information relevant to plaintiffs financial status or information that plaintiffs statements contained in his motion and declaration in support of motion to proceed in forma pauperis arc not true: I declare under penalty of perjury that the foregoing is true and correct, to the best of my howledge, information and belief. Signed this day of ,20-. Signature and Title of Records Officer of Prison ORDER Motion for leave to proceed in forma pauperis is Date: United States Magistrate Judge American LegalNet, Inc. www.FormsWorkFlow.com IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA Plaintiff, v. Defendant. 1 1 ) 1 Civil Action No. 1 1 1 AUTHORIZATION I,), T hereby authorize the custodian of my inmate account, upon order of a judge of the United States District Court of the Western Distn'ct of Pennsylvania, to (1) withdraw from my account and pay to the Clerk, United States District Court for the Western District of Pennsylvania, the initial partial filing fee (20% of the greater of the average monthly deposits to my account for the past six months, or the average monthly balance in my account for the past six months) and (2) if there remains any unpaid fee due and owing to the court, thereafter to set aside and accrue/freeze on a monthly basis twenty percent (20%) of the preceding month's deposits credited to my account and (3) each time the amount in my account exceeds $10.00 to forward to the Clerk the amounts accrued/frozen until the filing fee in the amount of $350 has been paid DATE American LegalNet, Inc. www.FormsWorkFlow.com