STATE OF WISCONSIN SUPREME COURT ­ COURT OF APPEALS, DISTRICT Appellant or Petitioner: Please print or type. For Official Use -vsRespondent: Prisoner's Petition for Waiver of Fees/Costs Affidavit of Indigency; Allegation of Imminent Danger Case No. Under oath I state that: · I am unable to prepay the costs of this action, special proceeding or appeal or to give security for those costs, and request waiver of those costs as permitted by law because of poverty. I am attaching and incorporating into this affidavit a brief statement of the nature of the appeal or petition and the relief requested. · I am in imminent danger of serious physical harm. Attached is a statement, under oath, detailing the facts concerning the immediacy of the danger and the type of physical injury claimed. (Be specific as to dates, times, places, participants, verbal or other claims made, what the danger is, and why the information should be believed.) Complete all sections. Failure to properly complete this petition/affidavit may result in the denial of the petition for waiver. Section 1. I currently receive: Supplemental security income Relief funded under Wis. Stats. §59.53(21) Medical assistance Food stamps Relief funded under public assistance Benefits for veterans under §45.351(1) or 38 USC 501-562 Legal representation from a civil legal services program, a public defender program, or a volunteer attorney program based on indigency. Name of program: Other means-tested public assistance: My financial situation has has not changed since I became eligible for this program. Section 2. 1. I am 2. I am 3. I earn $ am not am not married. employed. gross Name of employer: weekly. every 2 weeks. twice monthly. monthly. 4. I have received or been entitled to receive money from the following sources within the past 12 months (list total amount): pension, annuities, or life insurance payments: $ disability or worker's compensation payments: $ gifts, loans or inheritances: $ rent payments, interest or dividends: $ business, professional or self-employment: $ other: $ 5. I have the following cash assets: savings accounts: $ checking accounts: $ cash $ $ money owed me: $ other cash assets: $ 6. I have the following other assets (list value): real estate: $ stocks, bonds, securities and financial instruments: $ automobiles: $ computers, audio-visual equipment, other personal property: $ jewelry, antiques, objects of art or other valuable property: $ other: $ **File original with the Clerk of the Supreme Court ­ Court of Appeals.** $ $ Continued on Page 2 Wis. Stats. §814.29 American LegalNet, Inc. www.FormsWorkFlow.com AP-012, 09/04 Prisoner's Petition for Waiver of Fees/Costs- Affidavit of Indigency; Allegation of Imminent Danger Page 1 of 2 Prisoner's Petition for Waiver of Fees/Costs- Affidavit of Indigency; Allegation of Imminent Danger Page 2 of 2 Case No. Section 2 Continued: 7. I have the following legal obligations: Obligation Child Support Restitution Fines/Costs Other: Amount Actually Paid per Month $ $ $ $ $ $ $ $ Amount Actually Paid in Last 6 Months 8. My spouse is is not employed. Name of employer: 9. My spouse earns $ gross weekly. every 2 weeks. 10. My spouse receives monthly income totaling the amount of $ from: pension social security unemployment compensation disability student loans/grants other: 11. My spouse's household consists of myself and others: Full name: Full name: Full name: Full name: Full name: Relationship to me: Relationship to me: Relationship to me: Relationship to me: Relationship to me: twice monthly. monthly. Under age 18 Under age 18 Under age 18 Under age 18 Under age 18 Yes Yes Yes Yes Yes No No No No No 12. I have the following miscellaneous expenses: $ $ 13. Anticipated transcript costs for this appeal (as represented to me by the court reporter): $ Section 3 1. I am am not a person committed under chapter 980 (sexually violent person). 2. I am am not a person seeking relief from a judgment or order terminating my parental rights. 3. I am am not a person seeking relief from a judgment of conviction or sentence of a court, whether in a direct appeal or by collateral attack. 4. I am am not a person seeking appellate review under Rule 809.50 of an order or judgment not appealable as of right in a proceeding under chapter 980 or a case specified under Rules 809.30 or 809.40. 5. I am am not a person who is not serving a sentence for the conviction of a crime but who is detained, admitted or committed under chapter 51 or 55 or section 971.14(2) or (5). Section 4 · I have attached a copy of my authorization to the agency having custody of my prison trust fund account to forward payments from by account to the clerk of court each time the amount in the account exceeds $10 until the costs and fees are paid in full. Note: You may attach a brief explanation of circumstances you feel the court should be made aware of in determining indigency. Subscribed and sworn to before me on I understand that if my financial situation changes, I must notify the court immediately. Notary Public/State of Wisconsin My commission expires: Affiant Date AP-012, 09/04 Prisoner's Petition for Waiver of Fees/Costs- Affidavit of Indigency; Allegation of Imminent Danger Wis. Stats. §814.29 American LegalNet, Inc. www.FormsWorkFlow.com This form may be supplemented with additional material. Page 2 of 2