IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

QQc

\

y~c x cS

Plaintiff(s)/Petitioner(s)

vs. CIVIL ACTION NO.

`Xl,• tc°t;ac*c 1 ;~ tiat~cac (To be supplied by Clerk of Court)

Defendant(s)/Respondent(s)

MOTION TO PROCEED WITHOUT PREPAYMENT OF FEE S

I, . c ~j Ot1L,. ~d , a United States citizen, make this Motion to

Proceed Without Prepayment of Fees pursuant to Title 28 U .S .C. § 1915 in order to

proceed in forma pauperis in this action. I am unable to make prepayment of fees or to

give security therefor, and it is my belief that I am entitled to redress. I have not divested

myself of any property, monies or any items of value for the purpose of avoiding payment

of said fees.

1. BRIEF STATEMENT AS TO THE NATURE OF THE ACTION :

II. RESIDENCE:

Your address: *ft 2:07 ~ cl-\C:3 Oi W

YwwxCity

(City)

(Street)

(State) (Zip Code)

III. MARITAL STATUS :

1. Single X Married Separated Divorced

2. If married, spouse's full name :

IV. DEPENDENTS:

1. Number: 1

2. Relationship to dependent(s): uc+ (

3. How much money do you contribute toward your dependents ' support on

a monthly basis? $ 0

Revised 2/4/05

Case 3:06-cv-00740-MHT-SRW Document 2 Filed 02/13/2006 Page 1 of 7 Case 1:06-cv-00088-CB-M Document 2 Filed 02/13/2006 Page 1 of 7

V. EMPLOYMENT :

1 . Name of employer:

a. Address of employer :

n 1

(Street)

(City) (State) (Zip Code)

b. How long have you been employed by present employer?

Years: (\1 ( `` Months

c. Income: Monthly $ or Weekly $ A I

d. What is your job title? 11

2. If unemployed, date of last employment: 2O~

Amount of salary and wages received per month in last employment: $ F. '.Cra

3 . Is spouse employed? 1 CJ If so, name of employer: 1 A

13111, -

a. Income : Monthly $ or Weekly $

b. What is spouse 's job title? )'1 I 1

4. Are you and/or your spouse receiving welfare aid ? Li(jY1Lgvu+1

If so, amount: Monthly $ d}' or Weekly $

VI. FINANCIAL STATUS

1 . Owner of real property (excluding ordinary household furnishings and clothing) :

a. Description: -

b. Full Address:

c. In whose name:

d. Estimated value ------------------ $

e. Total amount owed -----; - i ------------ $

Owed to:

f. Annual income from property ------------------ $

Asset 2

b. Total cash in banks, savings and loan associations, prisoner accounts,

Make & Model :

In whose name registered?

Present Value of Asset :

Amount owed:

Owed to:

a. Asset 1

2. Other assets/property, such as automobiles, boats, motor homes, court

judgments, etc. (If more than two, list information on back) :

2

Case 3:06-cv-00740-MHT-SRW Document 2 Filed 02/13/2006 Page 2 of 7 Case 1:06-cv-00088-CB-M Document 2 Filed 02/13/2006 Page 2 of 7

financial institutions, other repositories, or anywhere else - $

c . List monies received by you during the last twelve (12) months, or held for you

by banks, savings and loan associations, prisoner accounts, other financial

institutions, or other sources as indicated below:

Business, profession or other forms of self-employment - $

Rent payments, interest or dividends - - - - - - - - - - - - - - $

Pensions, annuities or life insurance payments - - - - - - - $

Gifts or inheritances -------------------------- $

Stocks, bonds or notes ------------------------ $

Tax refunds, Veteran benefits or social security benefits $ ,

Any other sources --------------------------- $

3 . Obligations:

a. Monthly rental on house or apartment - - - - - - - - - - - - $

b. Monthly mortgage payments on house - - - - - - - - - - - - $

4. Other information pertinent to your financial debts and obligations :

( it~or) (Total debt) ~ (Monthly payment)

K I

(Creditor) (Total debt) (Monthly payment)

(Creditor) (Total debt) (Monthly payment)

5. If you have indicated that you have minimal or no assets or income , please

explain how you provide for your basic living needs such as food , clothing and

shelter. (e.g. food stamps, family assistance or charitable contributions .)

Other (Explain):

3

Case 3:06-cv-00740-MHT-SRW Document 2 Filed 02/13/2006 Page 3 of 7 Case 1:06-cv-00088-CB-M Document 2 Filed 02/13/2006 Page 3 of 7

VII. ALL PLAINTIFFS/PETITIONERS MUST READ AND SIGN :

I UNDERSTAND that any false statement(s) of a material fact contained herein may

serve as the basis of prosecution and conviction for perjury or making false statements.

FURTHER, I CERTIFY that all questions contained herein have been answered and are

true and correct to the best of my knowledge and belief.

DATE SIGr A!TURE OF PLA'NTIFF/PETITIONER

ADDRESS

ra~~n x

~~ ` c\ bar i 3 L(, O

4

Case 3:06-cv-00740-MHT-SRW Document 2 Filed 02/13/2006 Page 4 of 7 Case 1:06-cv-00088-CB-M Document 2 Filed 02/13/2006 Page 4 of 7

VIII. FOR PRISONER PLAINTIFFS/PETITIONERS ONLY:

A financial statement containing all transactions in your prisoner account for

the six (6) months immediately preceding the filing of the Complaint must

accompany this Motion. The financial statement must be in the form of a

computer printout or bank ledger card prepared by the institution ; a

notarized financial statement that you prepare; or a financial statement

prepared by an authorized officer of the institution. Failure to provide this

financial statement information may result in the dismissal of this action .

The requirement to submit the financial statement addressed above does not

negate your responsibility to ensure that the Certificate found below is also

properly executed and filed.

I hereby authorize the agency having custody of me to collect from my prison

account and forward to the Clerk of the United States District Court payments in

accordance with 28 U.S.C. § 1915(b)(2). I understand that even if I am allowed to proceed

in forma pauperis or pay a partial filing fee and even if my case is later dismissed for any

reason, I am obligated to pay to the Clerk of the Court the full amount of the filing fee

($250.00 for a civil action, $5.00 for a habeas corpus petition, or $255.00 for an appeal).

21y I No

DATE SIGNATURE OF PLA~NNIFF/PETITIONER

CERTIFICATE

(To be completed by the institution of incarceration)

I certify that the applicant named herein has the sum of $ I. 7

14, on account to

his/her credit at k ' •' (name of institution). I further certify that

during the past six months the aplilicant' s average monthly balance was $ _f'' - U" . I

further certify that during the past six months the average of monthly deposits to the

applicant's account was $ X . (Please attach a certified copy of the applicant's

account statement showing transactions for the past six months .)

lei

DATE -

SIGNATURE OF RIZED OFFICER

Case 3:06-cv-00740-MHT-SRW Document 2 Filed 02/13/2006 Page 5 of 7 Case 1:06-cv-00088-CB-M Document 2 Filed 02/13/2006 Page 5 of 7

RESIDENT TRANSACTION REPORT

Russell County Jai l

02/06/06 15:55

ST 001 /OPRRS

Page 1 of 2

NAMENUMBER 22502 8

Resident Name EDWARDS, JAMES TYRON E

Time Frame 05/18/2005 08 :09 - 02/06/2006 15 :5 5

Date Time Type ST OPR Receipt # Amount

05/18/2005 08 :09 Intake-Cash 1 jpt A80699 7 .4 6

05/23/2005 01 :17 Order-Swanson 1 rs A81127 7 .4 0

06/05/2005 20 :51 Order-Swanson-Indigent 1 jr A81935 1 .5 0

06/05/2005 20 :51 Receivable Write off 1 jr A81936 1 .5 0

06/26/2005 19 :50 Order-Swanson-Indigent 1 38 A83079 1 .5 0

06/26/2005 19 :50 Receivable Write off 1 38 A83080 1 .5 0

07/10/2005 21 :13 Order-Swanson-Indigent 1 jpt A84145 1 .5 0

07/10/2005 21 :13 Receivable Write off 1 jpt A84146 1 .5 0

07/17/2005 21 :49 order-Swanson-Indigent 1 rs A84600 1 .5 0

07/17/2005 21 :49 Receivable Write off 1 rs A84601 1 .5 0

07/24/2005 19 :57 Order-Swanson-Indigent 1 jpt A84997 1 .5 0

07/24/2005 19 :57 Receivable Write off 1 jpt A84998 1 .5 0

08/01/2005 00 :31 Order-Swanson-Indigent 1 rs A85536 1 .5 0

08/01/2005 00 :31 Receivable Write off 1 rs A85537 1 .5 0

08/15/2005 00 :25 Order-Swanson-Indigent 1 lg A86491 1 .50

08/15/2005 00 :25 Receivable Write off 1 lg A86492 1 .50

08/21/2005 21 :12 Order-Swanson-Indigent 1 jpt A86965 1 .5 0

08/21/2005 21 :12 Receivable Write off 1 jpt A86966 1 .50

08/24/2005 16 :21 Add-Cash 1 jpc A87194 10 .0 0

08/26/2005 23 :17 Add-Cash 1 rs A87255 10 .0 0

08/28/2005 23 :36 Order-Swanson 1 28 A87366 18 .7 8

08/28/2005 23 :36 Order-Swanson-Sales Tax 1 28 A87366 1 .2 1

09/11/2005 22 :25 Order-Swanson-Indigent 1 co45 A88382 1 .5 0

09/11/2005 22 :25 Receivable Write off 1 co45 A88383 1 .5 0

09/18/2005 21 :07 Order-Swanson-Indigent 1 jpt A88926 1 .5 0

09/18/2005 21 :07 Receivable Write off 1 jpt A88927 1 .5 0

09/25/2005 23 :18 Order-Swanson-Indigent 1 rs A89500 1 .5 0

09/25/2005 23 :18 Receivable Write off 1 rs A89501 1 .5 0

10/02/2005 21 :36 Order-Swanson-Indigent 1 jpt A89981 1 .5 0

10/02/2005 21 :36 Receivable write off 1 jpt A89982 1 .5 0

10/09/2005 19 :51 Order-Swanson-Indigent 1 gt A90362 1 .5 0

10/09/2005 19 :51 Receivable Write off 1 gt A90363 1 .5 0

10/16/2005 21 :55 Order-Swanson-Indigent 1 kls A90874 1 .5 0

10/16/2005 21 :55 Receivable Write off 1 kls A90875 1 .5 0

10/31/2005 00 :51 Order-Swanson-Indigent 1 38 A91923 1 .5 0

10/31/2005 00 :51 Receivable Write off 1 38 A91924 1 .5 0

11/07/2005 03 :08 Order-Swanson-Indigent 1 mj A92529 1 .5 0

11/07/2005 03 :08 Receivable Write off 1 mj A92530 1 .5 0

11/13/2005 14 :08 Add-Cash 1 CP A92754 25 .0 0

11/13/2005 23 :13 Order-Swanson 1 38 A93022 22 .5 4

11/13/2005 23 :13 Order-Swanson-Sales Tax 1 38 A93022 1 .5 1

11/20/2005 22 :08 Order-Swanson 1 C034 A93290 0 .7 1

11/20/2005 22 :08 Order-Swanson-Sales Tax 1 C034 A93290 0 .0 6

11/23/2005 01 :02 Add-Cash 1 flb A93588 15 .0 0

12/04/2005 22 :40 Order-Swanson 1 gt A94316 13 . 3 3

12/04/2005 22 :40 Order-Swanson-Sales Tax 1 gt A94316 1 .0 7

12/11/2005 22 :40 Order-Swanson 1 dtl A94664 0 .4 1

12/11/2005 22 :40 Order-Swanson-Sales Tax 1 dtl A94664 0 .0 3

12/19/2005 16 :15 Add-Cash 1 lg A95303 50 .0 0

12/25/2005 20 :07 Order-Swanson 1 33 A95483 14 .1 4

12/25/2005 20 :07 Order-Swanson-Sales Tax 1 33 A95483 0 .8 4

01/01/2006 22 :35 Order-Swanson 1 jr A95906 13 .4 6

01/01/2006 22 :35 Order-Swanson-Sales Tax 1 jr A95906 1 .0 8

01/06/2006 04 :03 Add-Cash 1 rs A96128 20 .0 0

01/08/2006 20 :45 Order-Swanson 1 jpt A96367 15 .2 5

01/08/2006 20 :45 Order-Swanson-Sales Tax 1 jpt A96367 0 . 9 1

01/16/2006 01 :43 Order-Swanson 1 rs A96826 20 .1 7

01/16/2006 01 :43 Order-Swanson-Sales Tax 1 rs A96826 1 .61

Case 3:06-cv-00740-MHT-SRW Document 2 Filed 02/13/2006 Page 6 of 7 Case 1:06-cv-00088-CB-M Document 2 Filed 02/13/2006 Page 6 of 7

RESIDENT TRANSACTION REPOR T

Russell County Jail

02/06/06 15:55

ST 001 /OPRRS

Page 2 of 2

NAMENUMBER 22502 8

Resident Name EDWARDS, JAMES TYRONE

Time Frame 05/18/2005 08 :09 - 02/06/2006 15 :5 5

Date Time Type ST OPR Receipt # Amount

01/23/2006 23 :55 Add-Cash 1 jr A97244 25 .0 0

01/29/2006 21 :58 Order-Swanson 1 gt A97595 14 .3 9

01/29/2006 21 :58 Order-Swanson-Sales Tax 1 gt A97595 0 .8 4

02/05/2006 20 :22 Order-Swanson 1 jpt A98059 10 .2 0

02/05/2006 20 :22 Order-Swanson-Sales Tax 1 jpt A98059 0 .82

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