Form 4170 "Declaration of Inmate Filing"

What Is Form 4170?

This is a legal form that was released by the United States Bankruptcy Court on December 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest available edition released by the United States Bankruptcy Court;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 4170 by clicking the link below or browse more documents and templates provided by the United States Bankruptcy Court.

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Download Form 4170 "Declaration of Inmate Filing"

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Form 4170 (12/18)
Declaration of Inmate Filing
________________________________________________
[insert name of court; for example,
United States District Court for the District of Minnesota]
In re ______________________ [insert debtor name]
__________________________, Plaintiff
v.
Case No. ______________
__________________________, 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. Bankr. P. 8002(c)(1) or Fed. R. Bankr. P.
8011(a)(2)(C).]
Form 4170 (12/18)
Declaration of Inmate Filing
________________________________________________
[insert name of court; for example,
United States District Court for the District of Minnesota]
In re ______________________ [insert debtor name]
__________________________, Plaintiff
v.
Case No. ______________
__________________________, 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. Bankr. P. 8002(c)(1) or Fed. R. Bankr. P.
8011(a)(2)(C).]