Fill and Sign the Civ 670 Prisoner Request for Filing Fee Exemption 12 14 Civil Forms

Page 1 of 2 AS 09.19.010 & .100 CIV-670 (12/14)(cs) Adm. R. 10(e), Crim R. 35.1(e) PRISONER REQUEST FOR FILING FEE EXEMPTION App. R. 204(b)(4) & 209(a)(6) IN THE DISTRICT/SUPERIOR/SUPREME COURT FOR THE STATE OF ALASKA AT ) ) ) ) ) ) ) ) ) CASE NO. ) ) PRISONER REQUEST FOR FILING FEE EXEMPTION I, , request exemption from paying (name of prisoner) part of the filing fee in this civil litigation against the State of Alaska. As required by AS 09.19.010, I am submitting to the court: 1. the following affidavit, and 2. the attached certified copy of my account statement for the past six months from the Department of Corrections. AFFIDAVIT I swear or affirm under penalty of perjury that the following information is true to the best of my knowledge and belief. 1. I am a prisoner at . (name of correctional facility) 2. I am attaching a filled out Financial Statement on court form CR-206. 3. The circumstances that prevent me from paying the full filing fee are: 4. Nature of action: application for post conviction relief civil lawsuit appeal of a civil judgment appeal from final decision of an administrative agency other: Page 2 of 2 AS 09.19.010 & .100 CIV-670 (12/14)(cs) Adm. R. 10(e), Crim R. 35.1(e) PRISONER REQUEST FOR FILING FEE EXEMPTION App. R. 204(b)(4) & 209(a)(6) 5. The following specific facts will, when proven, state a claim on which relief can be granted or entitle me to reversal on appeal: Date Prisoner's Signature Subscribed and sworn to or affirmed before me at , Alaska on . (date) (SEAL) Notary Public or other person authorized to administer oaths. My commission expires ORDER It is ordered that the above request is GRANTED. The court finds that exceptional circumstances prevent the prisoner from paying the full filing fee. The required filing fee will be $ (Minimum required by AS 09.19.010(d) is 20% of the larger of average monthly deposits to or average balance in prisoner's account.) DENIED. The court finds that no exceptional circumstances prevent the prisoner from paying the full filing fee. Notice: This case may be dismissed without further notice unless the required filing fee is paid within 30 days after the date of distribution of this order. Date Judge I certify that on a copy of this order was sent to: Type or Print Name Clerk: