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 Name - vs - Order on for Waiver of Prepayment of Fees/Costs Based on Imminent Danger Case No. COURT FINDINGS AND ORDER Documentation 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 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. Authorization to withhold money from prisoner trust fund and/or release account (on DOC form 1930 provided by the Department of Corrections. c. A properly completed affidavit of indigency (CV-440). d. Sufficient copies of the pleadings. e. 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 prison or jail 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 imminent danger determination. If box #4 is checked, do not consider the remaining sections. Continued on Page 2 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 Imminent Danger Determination: (Check box 5 or 6) 5. The prisoner has made a prima facie showing that he/she is in imminent danger of serious physical harm. 6. The prisoner has not made a prima facie showing that he/she is in imminent danger of serious physical harm. 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 sections. Economic Status Determination: (Check box 7 or 8) 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 and/or release 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 yet 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 DENIED because the court finds the prisoner is 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