_______________________
[insert name of court; for example,
United States District Court for the District of Minnesota]
A.B., Plaintiff
v.
W Case No.____
C.D., Defendant
I am an inmate confined in an institution. Today, ____ [insert date], I am depositing the ____ [insert title of document; for example, “notice of appeal”] in this case in the institution’s internal mail system. First-class postage is being prepaid either by me or by the institution on my behalf.
I declare under penalty of perjury that the foregoing is true and correct (see 28 U.S.C. § 1746; 18 U.S.C. § 1621).
Sign your name here____________
Signed on ________[insert date]
[Note to inmate filers: If your institution has a system designed for legal mail, you must use that system in order to receive the timing benefit of Fed. R. App. P. 4(c)(1) or Fed. R. App. P. 25(a)(2)(A)(iii).]