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N or jail and are not seeking immediate release under G.L. c. 248 1, but you are suing correctional staff and wish to request court payment of normal fees (for initial filing and service), do not use this form. Obtain separate forms from the clerk.) Court Case Name and Number (if known) Name of applicant: Address: (Street and number) SECTION 1: (City or town) (State and Zip) Under the provisions of General Laws, Chapter 261, Sections 27A-27G, I swear (or affirm) as follows: I AM I.

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