II 1fl( VATWI M Pflfl 

FILED 

MAR 26 2020 

I I I I I Jl U 1 CLERK, U.S. OISThIL' WESTERN 

Attachment 4 - MotioIEtQuiçJwwzzw Pauperis 

AO 240 (Rev. 01/09) Application to Proceed in District court Without Prepaying Fees or Costs (Short Form) 

UNITED STATES DISTRICT COURT 

for the 

District of 7e/ 

rvearitcr ) Plaintiff ) v. Civil Action No. 

Pilcilla Fonseco-Texas DFPS, Victona Marquez, Sharell ('lava 

HomeSafeJPathwavs 

Dfdant ) 0 CV 0 0 3 a 

APPLICATION TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS 

(Short Form) 

I am a plaintiff or petitioner in this case and declare that I am unable to pay the costs of these proceedings and that 

I am entitled to the relief requested. 

In support of this application, I answer the following questions under penalty of perjury: 

I. If incarcerated. I am being held at: 

If employed there, or have an account in the institution, I have attached to this document a statement certified by the 

appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any 

institutional account in my name. I am also submitting a similar statement from any other institution where I was 

incarcerated during the last six months. 

2. tnot incarcerated, if 1 am employed, my employer's name and address are: 

Social Security SSI 

My take-home pay or wages are: 783 per (apeeifv pay period) Monthly 

3. Other income. in the past 12 months. I have received income from the following sources (cheek all that apj'h): 

(a) Business, profession, or other self-employment 

(h) Rent payments. interest, or dividends 

(c) Pension, annuity, or life insurance payments 

(ci) Disability, or worker's compensation payments 

(e) Gifts, or inheritances 

(f) Any other sources 

11 Yes No 

1 Yes No 

1 Yes No 

lYcs No 

JYes XINo 

Yes XNo 

tyoii answered "Yes" to w:' question u/JOVe, descrthe below or on separate pages each source ofnioncv and state 

the amount that you received and what you expect to receive in the future. 

33 

Rev. Ed. October 26. 2017 

Case 3:20-cv-00083-KC Document 1 Filed 03/26/20 Page 1 of 3
A0 240 (Rev. 01/09) Application to Proceed in District Court Without Prepaying Fees or Costs (Short Form) 

4. Amount of money that I have in cash or in a checking or savings account: 

5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or 

thing of value that I own, includingany item of value held in someone else's name (describe the pivperty and its approximate 

value): 

rusT'] 

6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and pro ride the 

amount qf the month/v expensd: 

Iu] 

7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship with 

each person. and how much I contribute to their support: 

EH and KHT 

8. Any debts or financial obligations (describe the amounts owed and to whom they are payable): 

Student loans 

Declaration: I declare under penalty of perjury that the above information is true and understand that a false 

statement may result in a dismissal of my claims. 

Date: 03/18/2020 

Applicant's signature 

34 Rev. Ed October 26, 2017 

Case 3:20-cv-00083-KC Document 1 Filed 03/26/20 Page 2 of 3
Dennis Vanclusen 

Printed name 

Rev Ed. October 26. 2017 

Case 3:20-cv-00083-KC Document 1 Filed 03/26/20 Page 3 of 3