Statement Of Account {FL-E-LP-658}

FL/E-LP-658 PARTY AND CORRECTIONAL INSTITUTION (Name and Address): For Court Use Only X-REF NO: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO STREET ADDRESS: 3341 Power Inn Road MAILING ADDRESS: Same CITY AND ZIP CODE: Sacramento, CA 95826 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: STATEMENT OF ACCOUNT (Authorization By Inmate For Release of Financial Records) CASE NUMBER: I, ________________________________________________(name of inmate), identified by ________________ (X-Ref number), am applying for permission to make monthly payments towards the court fees for the filing of legal documents in a case with the Sacramento County Superior Court. I hereby authorize the appropriate personnel in the institution where I am incarcerated to release any and all information regarding my financial trust account to the Sacramento County Superior Court. DATE:________________________ SIGNED: ______________________________________________ PRINT INMATE'S NAME: ________________________________________________________________ __________________________________________________________ To Be Completed by the Correctional Institution CERTIFICATION REGARDING FUNDS IN INMATE'S ACCOUNT I, ____________________________________________ (NAME), work at the ________________________ ____________________________________________________ (NAME and ADDRESS of correctional institution) and act as the custodian of financial records for inmates in this facility. I certify that attached hereto is a true and correct copy of the inmate's statement of account from this institution. These records are maintained by personnel of this correctional facility in the ordinary course of business. Entries into the financial records are made at or near the time of the act of deposit or withdrawal of funds. I further certify that the average deposit each month to this inmate's account for the most recent 6-month period was $____________ and the average balance in the inmate's account each month for the most recent 6-month period was $____________. I certify that the above is true and correct. DATE: ___________ SIGNED: ______________________________________________________________ PRINT DECLARANT'S NAME AND TITLE:____________________________________________________ FL/E-LP-658 (Revised 6/20/2014) Optional STATEMENT OF ACCOUNT Gov. Code 68635 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com