F0RI( TO 35 IJSED DY FEDEL*LU4MAT5S 114 flUNOACML ACTIONUNDER 28 USC § 1351 OR 1546 IN THE UNITED STATES DISTRICT COURT 

FOR. THE EASTERN DISTRICT OF TEXAS 

TEXARKANA DIVISION 

N1t&iO UtittM1L LA 

(Enter above the fuilnarne and inmate number 

of plaintiff i this action) 

W/ISED 8105 

4PR 1 3 2020 

CLK. US. DISTRICT CLERK WESTERITTES 

DEPUTY 

v. SL2flCAO4B5 

(Clerk will assign the number) 

g i:k\JTh oJP1 

cThI1 Mt1 ozLE5 

(Enter above the fulL name of each defendant in this action). 

L PREVIOUS LAWSUITS: 

A. Have you fitedany other lawsuits in State or federal court dealing with the same 

facts involved in this action or otherwise relating to your imprisonment? _YES NO 

B. If your answer to "A' is "yes," describe each lawsuit in the space below. (If there is more than one 

lawsuit, describe the additional lawsuits on another piece of paper, giving the same information.) 

1. Approximate date of filing lawsuit: 

2. Parties to previous lawsuit 

Plaintifts) 

Defendant(s) 

3. Court: (If federal, name the disUict if state, name the county.) 

4. Docket Number 

S. Name of judge to whom case was assigned:. 

6. Disposition: (Was the casedisniissed, appealed, still pending?) 

7. Approximate date of disposition: 

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Case 5:20-cv-00563-DAE Document 24-5 Filed 03/03/21 Page 1 of 8
PLACE OF PRESENT 

UI. EXHAUSTION OP GRIEVANCE PROCEDI1BZS: 

Pusuant to 42 U.S.C. §l97e(a) xhauptIon oadnaJnIsfrative remedies is reqiired prior to initiating a civil rights action or Pe4çral Tort Claims Act 1awuXt. copies of all grievances peal and responsçs must be silbtnitted t6 verify xbaustion. Failuretodemonsfrate exhaustion irmy be grounds for .ismissal. The rules for federal prisoners are found at 

4 Lr.$,. 9 L1u,eI seq. 

1. Informal Grievance a. Did you submit an informal grievance Ifso, you must attach a copy of the grievance and response. 

b. 

cES ___NO 

2. Rormal Grievance 

a. Did you submit a fonnaIgiievance(DJ'9)? Ifso you must attach a copy of the grievance and response. 

b. 

7YES NO 

3. Appeal to the egi naDli'ee*orf the Bureau of Prisons 

r a. Didyoutmelysubmtanappealtothet(egi irtor-TU)? VIV " YES tfso,yournust attach a copy of the appeal and response. 

k If nnt then whvirnt? 

4. Appeal to the General Counselof the Bureau of Prisons 

a. Did you timely submit an appeal.to the General Counsel of the Bureau of Prisons (BP-1 1)? If so, you must attach a copy of the appeal and response. 

b. Tfii,t thn whit iw.t9 YES 

rv. PARTIES TO TS SUIT: 

A. meandaddressofeachplaintift !Y2.LO U%TMIIL.LJt 

ir CitMP1L kve.. 

1 71DZG 

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Case 5:20-cv-00563-DAE Document 24-5 Filed 03/03/21 Page 2 of 8
B. Fili name of each defendant, lila ocial position, his place of employment, and his full rnailin address. If you are bringing a civil rights lawsuit against federal employees, Uien your lawsuit should be filed pursuant to 28 US C § 1331 If you are bunguig a Pederal Tort Claims Act lawsuit under 28 1.1 S C § 1346, then the only defendant wilibe the United 

States of America. 

Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. 

uw"'t 

/ I vmt-tr 

Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. 

Defendant #3: 

11i(Ak 

4T 

fectn io 

Briefly describe the act(s) or omission(s) of this defendant which you claimed harmed you. 

i&c et6AS 'tos uifeê r&t. ôk ciL, oit ci k vi 

c o\edly Wvro.jn Cy, *Ukart, i4/evr iu .proce5$. 

Defcndant#4: MWI fer'7O daji tv v4 kV 

rh I Briefly describe the act(s) or omission(s) of this defendant which you claimed liatmed you. 

V. STATEMENT OF CLAIM: 

State here in a short and plain statement the facts ofyour:case, that is, what happened, where it happened, when it 

happened, and who was involved. Describe how defendant is involved. Do not give any legal arguments or cite any cases or statutes. If you intend to allege a number of related claims, number and set forth each claim in a separate 

paragraph. Attach extra pages if necessary, but remember that the complaint must be stated briefly and concisely. IF 

YOU VIOLATE THIS RULE, THE COURT MAY STRII YOUR COMPLAINT. 

'5 

4,if1 

EXHIBIT E

Case 5:20-cv-00563-DAE Document 24-5 Filed 03/03/21 Page 3 of 8
VIL 

v)e are yi,t &llgt,.,'ed c.øç,u uk'or t.e..s. 

RELIEF: State briefly exactly what you want the court to do for you. Make no legal arguments. Cite no cases or 

statutes. 

-, - - - . O r'.$r V(l#7 (, f 

GENERAL BAC1CGROVW INFOEMAflON P/ms.' a . vit( . 

1 

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4p( Ii')&t). 

f 7, 4: 

'3 YEV cr,-1 7 r*y 7*?p 

A. State, incomplete fonn, all names you have ever used or been known by including any and all aliases; 

B. List aR prisoner identification numbers you have ever been assigned and all other state or federal prison or FBI 

numbers ever assigned to you, if known t9 you. j3.4Sit, d,1'i r,'ihet z1d 

vrn. SANc.TIONS: 

A. Have you been Sanctioned by any court as a result of any lawsuit you have filed? 

B. If your answer is "yes," give the following infonnation for every lawsuit in which 

sanctions were imposed. (If more than one, use another piece of paper and answer 

the same questions.) 

1. Court that imposed sanctions (if federal, give the district and division): 

2. Docket Number: 

_YES/O 

3. Approximate date sanctions were ithpose&__________________________________ 

4. Have the actions been lined or otherwise satisfld? YES NO 

C. Has any court ever warned or notified you that sanctions ccold be imposed? ___YES NO 

4 

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Case 5:20-cv-00563-DAE Document 24-5 Filed 03/03/21 Page 4 of 8
D. If your answer is "yes", give the following infomation for every lawsuit in which 

warning was imposed. (If more than one, use anotherpiece of paper and answer 

tie same questions.) 

:1. Court that imposed warning (if federaj, give the lisfrict and division): N('4 

2. Docket Number: 

3. Approximate date warnings were imposed:________________________________ 

Signed this day of Af'ti 1 .2020. 

(date) (rnonth) (year) 

- 

I DECLARE (OR CERTifY, VERIFY OR STATE) uNDER PENALTY OF PERJURY ifiAT TUE 1?OREGOING 

STATEMENTS OF FACT, INCLUDING ALL CONTINUATION PAGES, ARE TIWZ AND CORRECT. 

Executed on: _ i / _ á'1 202 

I (Date) H 

(i tUreofLpIainti) 

WARNING: The Plaintiff Is hereby advised any fake Or deliberately misleading information provided in response to the 

following questions Will result In the imposition of sanctiOns. The sanctions the Court may Impose Inelde, but are not 

limited to monetary sanctions and/or the dismissal of this action with prejudice. 

EXHIBIT E

Case 5:20-cv-00563-DAE Document 24-5 Filed 03/03/21 Page 5 of 8
Money Receipts with Gift Cards 0 

9406: QuintaniHa, Mario- Transactions From 11/7/2019 12:00 AM to 4/7/2020 11:59 PM 

dd#I 

180062 0 GiftCard Gift Card Fund $50.00 

3/22/2020 JaIIATM Web Deposit GC# 23058280 by Guadatupe Ramirez 

17 çft Cçcf Fun . Y 2500 

efenn4Mcra!es 

176110 0 GiftCard Gift Card Fund $45.00 

3/1/2020 Ja1IATM Web Deposit GC# 22602511 by Guadalupe Rarnirez 

d LGLtCrd4Fun 

H I 173672 0 GiftCard Gift Card Fund $90.00 

2118/2020 JaIIATM Web Deposit GC# 22345220 by Guadalupe Ramirez i.Ii: S: : 171090 0 GiftCard Gift Card Fund $100.00 

2/3/2020 JaIIATM Web Deposit GC# 22043503 by Guadalupe Ramirez 

$10000 

g 

169627 0 GiftCard Gift Card Fund $50.00 

1/26/2020 .JaIIATM Web Deposit GC# 21898023 by Guadalupe Ramfrez 

$5000 

167596 0 GiftCard Gift Card Fund $40.00 

1/1212020 JaIIATM Web Deposit GO# 21639452by Guadalupe Rarnirez 

1r: 

: 

;S 

: : /4 Qppsir V 

166719 0 GiftCard GiftCard Fund $20.00 

113/2020 JaiIATM WebDeposit GC# 2i502250 by Guadalupe Ramirez 

165908 0 GiftCard Gift Card Fund $25.00 

12127/2019 del/ATM Web Deposit G# 21366876 by Guadalupe Rarnirez 

rupd $69 00 

5 ;S::5 

Printed 04/07/2020 07:25 PM Confidential Property of Atascosa TX Page 1 of 2 

Printed By: IWILLIAMS 

EXHIBIT E

Case 5:20-cv-00563-DAE Document 24-5 Filed 03/03/21 Page 6 of 8
Money Receipts with Gift Cards 

': Total Cash: $0.00 

Total Checks: $0.00 

Total Money Orders: $000 

Total Other: $905.00 

Cash Drawer Total: $905.00 

Prind 0410712020 07:25 PM ConidentEI Property oC Atascosa TX Page 2 or 2 

Printed By: IWLLIAMS 

EXHIBIT E

Case 5:20-cv-00563-DAE Document 24-5 Filed 03/03/21 Page 7 of 8
(12 ..kS.C.A 

REVISED 08/05 

It 

UNITED STATES DISTRICT COURT 

OFFICE OF THE CLERIC EASTERN DISTRICT OP TEXAS 

RB: Your request for Fornis for filing a Civil Rights Complaint 

PEDERAL. 133111346 

The forms you requested arc enclosed. Please rezd the forms and follow the instructions very carefully. Make certain you have 

answered all the questions and have signed in all the required places. 

The filing fee for this type of civil action is $400.00 If you pay the $400.00 now, you must submit your cbck or money order 

made payable to the Cleric u.S. District Court, together with your complaint If you are permitted to proceed InformapauperLc, 

the fee is $350 and the Court will permit you to pay the the according to a payment plan established by the Court 

If you are unable to pay the filing fee and service costs for this complaint, you may request the Court to allow you toproccedln 

JbrmapauperisaFP) (appitcatlon enclosed), if you use this form, you must answer each and every question and sign the form. If you are a federal inmate, you must obtain a certified print out of your trust fund account from the fecility in which you arc incarcerated. DO NOT SEND THE COM1'LANT WITHOUT A CERTIFIED SIX (6) MONTH HISTORY OR PRINT 

OUT OF YOUR TRUST FUND ACCOUNT OR EQUIVALENT. Otherwise your case cannot be processed and will be 

delayed until you comply with the data sheet 

Please give special attention to the following Information: 

PARTIES: The parties to a law suit arc the plaintiff (the person who is filing the suit) and the defendant (the person who 

is being sued.) List the Ml names of each defendant on page 1. If you cannot obtain the full names or 

supply an initial, state the name as Unknown. On page 3, list the defendant(s) again with a full address. If 

there is more than one defendant, the defendants should be listed in the same order as on page 1. If there is more than one plaintI each plaintiff must be listed with their prison I.D. number and must sign the 

complaint on the last page. Each plaintiff must also submit a separate and completed 1FF form. If you are bringing a civil rights lawsuit against federal employees, then your lawsuit should be filed pursuant to 28 

U.S.C. § 1331. If you ure bringing a Federal Tort Claims Act lawsuit under 28 U.S.C. § 1346, then the only 

defendant will be the United States of America. 

STATEMENT It is very important you state a claim against each named defendant. Give only the lhcts without legal 

OF CLAIM: arguments or case law. 

FILING: Submit only the original complaint to the Court Keep a copy for your records. Once the original is filed, it 

cannot be returned unless ordered by the Cowl. Use a typewriter or black ink Your complaint must be 

legible and in English. Do not use legal size paper. Use standard size paper (8 !4 x 11 inches) only. Do not 

write on the reverse side of any page. Leave space (margins) at each side and on the top and bottom of the 

page. Complaints which do not conform to these instructions will be returned with a notation as to the 

deficiency so they may be corrected. 

It is your responsibility to keep the Court informed of your current address. If you are transferred or released, you must file a 4?4mi of Change of Address" with the Clerk. You must ilso certify that you have sent 

notice to the defendant's attorney (if any). Failure to follow this rule may result in your case being 

dismissed. 

VENUE: Your complaint can be brought in this Judicial District if at least one of the defendants reside in this district 

or the cause of action arose In this district. If not, you are in the wrong court. A complaint submItted to the 

wrong court will only delay the proceedings. 

Finally, do not write letters to the Clerk or the Judges asking for advise. The court can only act on motions 

and does not advise litigants as to the law or procedures. 

Thank you for your cooperation. 

Case 

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