Authorization To Debit Prison Inmate Account (Page 5 of 6) in pdf

Authorization To Debit Prison Inmate Account Page 5

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF IOWA

______________________ DIVISION

________________________________,

Case No. C__________________

Plaintiff,

APPLICATION TO APPEAL

vs.

________________________________,

IN FORMA PAUPERIS

Defendant.

I, __________________________________________, declare that I am the

Plaintiff in the above-entitled proceeding; that in support of my request to proceed

without being required to prepay the full filing fee, I state that because of my poverty, I

am unable to prepay the full $455.00 filing fee for this appeal; and that I believe I am

entitled to relief.

In further support of this application, I answer the following questions:

Where are you imprisoned?

_______________________________________________________

When did you begin your imprisonment there?

_______________________________________________________

When do you expect to be released?

_______________________________________________________

Are you presently receiving an allowance or wage from the prison or jail?

______________________

If the answer is YES, state the amount of your allowance or wages per

month.

______________________.

Within the past twelve (12) months, have you received any money from a

business, profession or other type of self-employment, or in the form of

rent payments, interest, dividends, retirement or annuity, gifts inheritances,

court award or settlement, or other sources? _______. If YES, give the

amount received and identify the sources.

___________________________________________________________

Authorization To Debit Prison Inmate Account Page 5