Certificate Of Custodial Institution

UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE ___________________________ v. ___________________________ Case No. _______________________ ATTACHMENT TO MOTION/AFFIDAVIT TO PROCEED IN FORMA PAUPERIS WITHOUT PREPAYMENT OF FEES CERTIFICATE OF CUSTODIAL INSTITUTION Name of Inmate: Name of Institution: Address of Institution: ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ 1. I hereby certify that for the six-month period immediately preceding this date the applicant has had average monthly deposits to his/her account of $_____________. 2. Further, I certify that for the six-month period immediately preceding this date the applicant has maintained an average monthly balance in his/her account of $_____________. 3. I attach a certified copy of the applicant's trust account statement for the six months preceding the submission of this certificate. ___________________________________ Authorized Officer of Institution __________________________________ Title ___________________________________ Date USDCNH-14 (Revised 8-00) (Previous Editions Useable) American LegalNet, Inc. www.USCourtForms.com