CV- Affidavit of Indigency 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 - of Prepayment of Fees/Costs Based on Imminent Danger Affidavit of Indigency Case No. (The prisoner must provide the following to the Clerk of Court at the time of filing: The original and one copy of this affidavit and attachments. Sufficient copies of the pleadings for potential service on all named defendants.) UNDER OATH I STATE: 1. I am unable to pay the costs of this action, special proceeding or appeal or to give security for those costs, and request waiver of those costs because of poverty. 2. 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 harm claimed. (Be specific as to dates, times, places, participants, verbal or other claims made, what the danger is, and why information should be believed.) 3. I have attached and incorporated into this affidavit: A copy of my pleading(s) in this matter. [If this proceeding is related to prison or jail conditions]: Written documentation of exhaustion of all available administrative remedies concerning the subject of these pleadings, including copies of all written materials: I provided to the administrative agency as part of the administrative proceeding; the administrative agency provided to me related to the administrative proceeding; and, included as part of any administrative appeal. My authorization to the agency having custody of my prison trust fund account (on DOC form 1930 provided by the Wisconsin Department of Corrections), to forward payments from my account to the clerk of court each time the amount in the account exceeds $10, until the costs and fees are paid in full. 4. I have have not committed an offense on or after September 1, 1998. (An offense is defined in 247165.83(1)(c), Wisconsin Statutes, as an act which is a felony, misdemeanor, or violation of a city, county, village, or town ordinance. 5. I am am not employed. Name of employer: 6. I earn $ gross weekly. every two weeks. twice monthly. monthly. 7. I have received or been entitled to receive money from the following sources within the past 12 months (list total amount received): pension, annuities or life insurance payments: ............. $ disability or worker's compensation payments: ............. $ gifts, loans or inheritances: ...................................... $ rent payments, interest or dividends: ............................ $ business, profession or self employment: ..................... $ other: ...................................... $ 8. I have the following cash assets: savings accounts: .................. $ checking accounts: ................ $ cash: .............................. $ money owed me: ................... $ any other cash assets: .......... $ Original: Clerk of Circuit Court Continued on Page 2 American LegalNet, Inc. www.FormsWorkFlow.com CV- Affidavit of Indigency 247814.29, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 9. 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 : .... $ 10. I have not transferred any funds or other assets in the past 12 months except as follows (describe any transfers): 11. I have not assigned my rights to any funds or other assets since first incarcerated except as follows (describe any assignments): 12. I have the following legal obligations: Obligation Amount Actually Paid Per Month Amount Actually Paid in Last Six Months Child Support $ $ Restitution $ $ Fines/Costs $ $ Other: $ $ 13. My spouse is is not employed. Name of employer: 14. My spouse earns $ gross weekly. every two weeks twice monthly monthly. 15. My spouse receives monthly income totaling the amount of $ from: Pension Social Security Unemployment compensation Disability Student loans/grants Other: 16. I have the following miscellaneous expenses: I understand that if my financial situation changes, I must notify the court immediately. State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Signature Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com