UNITED STATES DISTRICT COURT EASTERN DISTRICT OF WISCONSIN ________________________________ Full name of plaintiff(s) v. ________________________________ Full name of defendant(s) Case No. ___________________________ (Provided by the Clerk of Court) Answer the following questions to the best of your ability. Note: If you do not tell the truth, the Court may dismiss your lawsuit. I. Personal Information 1) Your name: ___________________________________________________________ (a) State the place of your incarceration and provide your prisoner identification number: _______________________________________ _____________________________ (place) (number) (b) Are you employed at the institution? Yes No (c) Do you receive any payment from the institution? Yes No Attach a printout of your prison trust account statement showing transactions for the sixmonth period immediately preceding the filing of this request and showing the current balance of your account. PRISONER REQUEST TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING THE FULL FILING FEE Fee Request ­ 2 American LegalNet, Inc. www.FormsWorkFlow.com 2) Do you have any dependents that you are responsible for supporting? Yes No If "yes," list them below. Name or initials (for Relationship to You Age Amount of Support minor children only) Provided per Month ________________________ _________________ ________ $____________ ________________________ _________________ ________ $____________ ________________________ _________________ ________ $____________ II. Property or Assets If you are married, your answers must include your spouses property. 1 ) Do you own a car? Yes No If "yes," list the car(s) below: Make and Model Year Approximate Current Value _______________________________________________ __________ $________________ _______________________________________________ __________ $________________ 2) Do you own your home(s)? Yes No If "Yes," state the approximate value(s). $ ____________________ What is the amount of equity (assessed value of residence minus outstanding mortgage balance) in the home(s)? $ ____________________ 3) Do you have any cash or checking, savings, or other similar accounts? Yes No If "Yes," state the total of such sums. $ ____________________ Fee Request ­ 3 American LegalNet, Inc. www.FormsWorkFlow.com 4) Do you own any other property of value, such as real estate, stocks, bonds, trusts, or individual retirement accounts (e.g., IRA, 401 k), artwork, or jewelry? Yes No If "Yes," describe the property and the approximate value(s). ______________________________________________________________________ ______________________________________________________________________ Litigation History III. For each federal lawsuit that you recall having filed, list as much of the following information that you remember about each case: The name of the case (that is, the plaintiffs and the defendants), the case number or year of filing, and the federal district in which you filed the case. Use more paper if needed. Case Name Case number Federal district (Plaintiffs and defendants) (or year of filing) ________________________ ____________________ _______________________ ________________________ ____________________ _______________________ ________________________ ____________________ _______________________ ________________________ ____________________ _______________________ ________________________ ____________________ _______________________ Fee Request ­ 4 American LegalNet, Inc. www.FormsWorkFlow.com IV. Other Circumstances Describe any other financial circumstance(s) that you would like the Court to consider when reviewing this petition. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ I, ____________________, declare that I am the plaintiff bringing this complaint. I declare that I am unable to prepay the full filing fee and that I am entitled to the relief sought in the complaint. I declare under penalty of perjury that the foregoing is true and correct. ___________________________ _________________________________________ Date Signature Fee Request ­ 5 American LegalNet, Inc. www.FormsWorkFlow.com