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CV-4 4 1, 1 0/0 6 O rd e r o n P ris o n er's P etit io n f o r W aiv e r o f P re p aym en t o f F ees/C osts B ase d o n Im min e nt D an ger §81 4.2 9, W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l. P age 1 o f 2 S TA TE O F W IS C O NSIN , C IR CUIT C O URT, C O UNTY -v s- O rd er o n P ris o ner’s P etit io n f o r W aiv e r o f P re p aym en t o f F ees/C osts B ased o n Im min en t D an ger C ase N o. For O ff ic ia l U se C O URT F IN DIN G S A N D O RDER D ocu m en ta tio n R ev ie w D ete rm in atio n: ( C heck b ox 1 o r 2 ) 1 . T he p ris o ner h as s u bm it te d a ll r e qu ir e d d ocu m enta tio n . 2 . T he p etit io n is D EN IE D b eca use th e p ris o ner f a ile d to p ro vid e th e f o llo w in g d ocu m enta tio n: a . E xh austio n o f a dm in is tr a tiv e r e m edie s ( re quir e d if th e u nderly in g p ro pose d a ctio n r e la te s to p ris o n o r ja il c o ndit io ns: docu m ents th e p ris o ner p ro vid ed to t h e a dm in is tr a tiv e a gency a s p art o f th e a dm in is tr a tiv e p ro ce ed in g ; docu m ents f r o m th e a dm in is tr a tiv e a g ency p ro vid ed to th e p ris o ner r e la te d t o th e a dm in is tr a tiv e p ro ce ed in g ; a n d/o r, docu m ents in clu ded a s p art o f a n y a dm in is tr a tiv e a p pe al. b . A uth oriz a tio n to w it h ho ld m one y f r o m p ris o ner tr u st f u nd a n d/o r r e le ase a cco unt ( o n D O C f o rm 1 930 p ro vid e d b y t h e D epartm ent o f C orre ctio ns. c . A p ro perly c o m ple te d a ffid a vit o f in d ig ency ( C V-4 4 0). d . S uffic ie nt c o p ie s o f th e p le a din gs. e . O th er: If b ox # 1 is c h ecke d, p ro ce ed to th e e xh a ustio n o f a d m in is tr a tiv e r e m edie s d ete rm in atio n. If b ox # 2 is c h ecke d, d o n o t c o nsid er t h e r e m ain in g s e ctio ns. E xh au stio n o f A dm in is tr a tiv e R em ed ie s D ete rm in atio n: ( C heck b ox 3 o r 4 ): 3 . T he p ris o ner h as e it h er e xh auste d a ll a va il a b le a dm in is tr a tiv e r e m edie s o r is n ot r e quir e d to d o s o b eca use t h e u nderly in g p ro pose d a ctio n d o es n ot r e la te t o p ris o n o r ja il c o n dit io ns. 4 . T he p ris o ner h as n ot e xh a uste d a ll a va ila b le a dm in is tr a tiv e r e m edie s. T he p etit io n to p ro ce ed w it h ou t p re pa ym ent o f f ilin g f e es a nd c o sts is D EN IE D . If b ox # 3 is c h ecke d, p ro ce ed to th e im min en t d a ng er d ete rm in atio n. If b ox # 4 is c h ecke d, d o n o t c o nsid er t h e r e m ain in g s e ctio ns. I m min en t D an ger D ete rm in atio n: ( C heck b ox 5 o r 6 ): 5 . T he p ris o ner h as m ade a p rim a f a cie s h ow in g t h at h e/s h e is in im m in ent d an ger o f s e rio us p h ys ic a l h arm . 6 . T he p ris o ner h as n ot m ade a p rim a f a cie s h ow in g t h at h e/s h e is in im m in ent d ang er o f s e rio us p h ys ic a l h arm . The p etit io n to p ro ce ed w it h out p re p aym ent o f f ilin g f e es a nd c o sts is D EN IE D . If b ox # 5 is c h ecke d, p ro ce ed to th e e co n om ic s ta tu s d ete rm in atio n. If b ox # 6 is c h ecke d, d o n o t c o nsid er t h e r e m ain in g s e ctio ns. Contin ued o n P ag e 2 Ord er o n P ris o ner©s P etit io n f o r W aiv er o f P re p aym en t o f F ees/C osts B ased o n Im m in en t D an ger Pag e 2 o f 2 Case N o. C V-4 4 1, 1 0/0 6 O rd e r o n P ris o n er's P etit io n f o r W aiv e r o f P re p aym en t o f F ees/C osts B ase d o n Im min e nt D an ger §81 4.2 9, W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l. P age 2 o f 2 E co nom ic S ta tu s D ete rm in atio n: ( C heck b ox 7 o r 8 ): 7 . T he p etit io n is G RAN TE D b eca use : • The p ris o ner is in dig ent; • The p ris o ner a uth oriz e d in w rit in g th e a gency h avin g c u sto d y o f th e p ris o n er's p ris o n tr u st f u nd a nd /o r r e le ase a cco unt to f o rw ard p a ym en ts f r o m th e p ris o n er's a cco unt to th e c le rk o f c o u rt e ach t im e th e a m ount in t h e a cco unt e xce eds $ 1 0 u n til th e f e es o r c o sts a re p aid in f u ll. The a gency h a vin g c u sto d y o f th e p ris o ner's p ris o n tr u st f u nd a nd /o r r e le ase a cco unt s h a ll f r e e ze t h e p ris o ner's tr u st f u nd a nd /o r r e le ase a cco unt w hile s u ch p a ym ents a re b ein g m ade a nd s h all f o rw ard th e p a ym en ts to t h e c le rk o f c o u rt a s p ro vid ed b y la w . The a ctio n m ay b e c o m m en ce d w it h o ut p re pa ym ent o f f ilin g f e es. T he s h erif f s h all s e rv e a ll n ece ssa ry d ocu m ents w it h o ut p re pa ym ent o f s e rv ic e f e es. If th e p ris o ner r e ce iv e s a m one y ju dgm ent o r m oneta ry s e ttle m ent, th e a m ount s h a ll b e u se d to p a y t h e f il in g a nd s e rv ic e f e es w aiv e d b y th is o rd er w hic h h a ve n ot y e t b een r e im burs e d p urs u a nt t o th e p rio rit y s ch edu le in § 8 06.0 25(2 ), W is co nsin S ta tu te s. The c le rk o f c o urt s h all n otif y th e c u sto d ia n a t th e p ris o ner's f a cilit y o f th e to ta l f il in g f e es, c o sts a nd s e rv ic e f e es a s s o on a s a sce rta in a ble . 8 . T he p etit io n is D EN IE D b eca use th e c o urt f in ds th e p ris o ner is n ot in d ig e nt. T he f il in g a nd s e rv ic e f e es m ust b e p aid in f u ll b efo re c o m mence m ent o f th is m atte r. BY T H E C O URT: Cir c u it C ourt J u d ge Nam e P rin te d o r T yp ed D is tr ib utio n: 1 . Cle rk o f C ourt ( O rig in al) 2 . Petit io ner 3 . Departm ent o f J u stic e , C iv il L it ig atio n U nit P.O . B ox 7 857, M adis o n, W I 5 3707 -7 857 4 . Departm ent o f C orre ctio ns F acilit y a t w hic h p etit io ner is in ca rc e ra te d (D odge C orre ctio nal In stit u tio n, if o ut o f s ta te ) Date