______________________________________________

[insert name of court; for example,

United States District Court for the District of Minnesota]

A.B., Plaintiff

v.

}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).]