CV- 247814.29, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY - vs - Waiver of Prepayment of Fees/Costs Case No. COURT FINDINGS AND ORDER Document Review Determination: (Check box 1 or 2) 1. The prisoner has submitted all required documentation. 2. The petition is DENIED because the prisoner failed to provide the following documentation: a. Exhaustion of all available administrative remedies (required if the underlying proposed action relates to prison or jail conditions): documents the prisoner provided to the administrative agency as part of the administrative proceeding; documents from the administrative agency provided to the prisoner related to the administrative proceeding; and/or, documents included as part of any administrative appeal. b. Original Wisconsin Department of Justice certification (form DJ-LS-22) concerning prior dismissals dated within thirty days of the date of the petition. Document to have raised seal; a copy is insufficient. c. Authorization to withhold money from prisoner trust fund account (on DOC form 1930 provided by the Department of Corrections). d. A certified copy of the prisoner trust fund account for the six months preceding the date of the petition. e. A properly completed affidavit of indigency (form CV-438). f. Sufficient copies of the pleadings. g. Other: If box #1 is checked, proceed to the exhaustion of administrative remedies determination. If box #2 is checked, do not consider the remaining sections. Exhaustion of Administrative Remedies Determination: (Check box 3 or 4) 3. The prisoner has either exhausted all available administrative remedies or is not required to do so because the underlying proposed action does not relate to jail or prison conditions. 4. The prisoner has not exhausted all available administrative remedies. The petition to proceed without prepayment of filing fees and costs is DENIED. If box #3 is checked, proceed to the three dismissals determination. If box #4 is checked, do not consider the remaining sections. American LegalNet, Inc. www.FormsWorkFlow.com CV- 247814.29, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 Three Dismissals Determination: (Check box 5 or 6) 5. The prisoner has not accumulated three or more dismissals pursuant to 247801.02(7)(d), Wisconsin Statutes, or is not subject account to pay the filing fee in full. 6. The prisoner has, on three or more prior occasions, while he or she was incarcerated, imprisoned, confined or detained in a jail or prison, brought an appeal, writ of error, action or special proceeding, including a petition for a common law writ or certiorari, that was dismissed by a state or federal court for the reasons listed in 247802.05(3)(b) 1 to 4. The petition to proceed without prepayment of filing fees and costs is DENIED. If box #5 is checked, proceed to the economic status determination. If box #6 is checked, do not consider the remaining section. Economic Status Determination: (Check box 7, 8, or 9) 7. The petition is GRANTED because The prisoner is indigent; The prisoner authorized in writing the agency having custody of the prisoner's prison trust fund and/or release account to forward payments from the prisoner's account to the clerk of court each time the amount in the account exceeds $10 until the fees or costs are paid in full. The agency having custody of the prisoner's prison trust fund and/or release account shall freeze the prisoner's trust fund account while such payments are being made and shall forward the payments to the clerk of court as provided by law. The action may be commenced without prepayment of filing fees. The sheriff shall serve all necessary documents without prepayment of service fees. If the prisoner receives a money judgment or monetary settlement, the amount shall be used to pay the filing and service fees waived by this order which have not been reimbursed pursuant to the priority schedule in 247806.025(2), Wisconsin Statutes. The clerk of court shall notify the custodian at the prisoner's facility of the total filing fees, costs and service fees as soon as ascertainable. 8. The petition is CONDITIONALLY GRANTED. The court finds the prisoner to be partially indigent because the prisoner has assets in his/her trust fund account to partially pay the filing and service fees. Upon payment by the prisoner of $ (the balance in his/her trust fund and/or release account as shown by the certified copy of his/her trust account statement) or the required filing fee, whichever is less, this action may be filed and all necessary documents may be served by the sheriff. If payment is not made within 30 days of this Order, the petition is DENIED. The clerk of court shall notify the custodian at the prisoner's facility of the total filing fees, costs and service fees as soon as ascertainable. The agency having custody of the prisoner's prison trust fund and/or release account shall freeze the prisoner's trust fund and/or release account until the deposits in that account are sufficient to pay the balance owed and shall forward the balance to the clerk of court as provided by law. 9. The petition is DENIED because the court finds the prisoner not indigent. The filing and service fees must be paid in full before commencement of this matter. DISTRIBUTION: 1. Clerk of Court 2. Petitioner 3. Department of Justice, Civil Litigation Unit P.O. Box 7857, Madison, WI 53707 - 7857 4. Department of Corrections Facility at which petitioner is incarcerated (Dodge Correctional Institution, if out of state) American LegalNet, Inc. www.FormsWorkFlow.com