Application For Exemption From Filing Fee Form
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1
2IN THE SUPREME COURT OF THE STATE OF ALASKA
APPLICATION FOR EXEMPTION FROM FILING FEE
For Use in Prisoner Civil Appeals Against the State of Alaska
Under AS 9.19.010 - 100
Print Form
Instructions: Complete only if Appellant seeks a filing fee exemption under AS 9.19.010. If a filing fee exemption is sought, this
form must be completed, and the documents listed in Item 3 must be attached. A waiver of cost bond must be sought by separate
motion.
1. Appellant’s Name:
2. Appellant’s Affidavit:
a. I am a prisoner as defined in AS 33.30.901.
b. My complete financial situation, including my income, assets and court ordered payments is accurately and fully set out
in the attached Supreme Court/Court of Appeals Financial Statement Form.
c. The following circumstances prevent me from paying a full filing fee:
(Continue on back if necessary.)
Continue this explanation
d. Nature of the action or appeal (Include specific facts that, if proved, would entitle Appellant to a reversal on appeal):
(Continue on back if necessary.)
Continue this explanation
3. Attached documents:
a. Supreme Court/Court of Appeals Financial Statement.
b. Certified copy of Appellant account statement from the Department of Corrections for the six-month period
preceding the date of this application.
4. Oath: I declare under oath that all statements made in this application are true.
___________________________________
________________________________________________________
Date
Appellant’s Signature
Subscribed and sworn to or affirmed before me on _________________________, 19_____ in _________________________
Alaska.
_______________________________________________________
(SEAL)
Notary Public
My commission expires: ___________________________________
Proof of Service: I certify that on ___________________________ a copy of this application and attachments was mailed to
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Signature: _______________________________________________
SCT - 919app(rev.1/98)
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