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NOTICE 

A TC-060 (Rev. 7) 

Attachment 2 

OFFENDER NOTARY PUBLIC SERVICE 

Under both Federal law (28 U.S.C § 1746) and State law (V.T.C.A. Civil Practice & Remedies 

Code, § 132.00 1-132.003), offenders incarcerated in Texas may use an unsworn declaration under 

penalty of perjury in place of a written declaration, verification, certification, oath, or affidavit 

sworn before a Notary Public. 

In a request for Notary Public service, each offender must explain why an Unsworn Declaration is 

insufficient before Notary Public service will be provided . 

.................... , ........................................................ . An examplt? of an unsworn declaration pursuant to State law is as follows: 

"My name i• Dahft 

'(First) f?uc/c 

(Last) 

my date of birth is 5,2 J- ~ 7 , 

and my inmate identifying number, is /o/1 ?ff 0 q . I am presently incarcerated in 

-r-12-~--r'=.~.c!c_;;,..c -Jot4.,.L-{,Io.,q..;:.¢.....>=::e..::....___.i.f/4-'t4C+-~-!-L, r ___ · in CoLo racfa C/ J-r r!'YVJ::~I ~ r(Correcti~it name) (City) 

-1-I-I-L'-~-L....>oo~+~ .......... Yd.....,ec'"'"LL""""'" ___ -Lk..J--t!-"'------'":1<-=--q..r..._.S:'-+-/-.<2::::::-----· I declare under penalty of 

(County) (State) (Zip Code) 

perjury that the f~ng i• true and correct. 

61 7 

Executed on the day of Oec;?)k ~er, 20-4:-

···················································*·························· An example of an unsworn declaration pursuant to Federal law is as follows: 

______________ .(insert offender name and TDCJ number), being 

presently incarcerated in (insert TDCJ unit name), in 

_________ County, Texas, declare under penalty of perjury that the foregoing is true 

and correct. 

Executed on the ___ day of , 20 __ . ) _______ , 

(Offender Signature) 

****************************************************************************** 

NOTICE 

NOTARY PUBLIC SERVICE DENIAL 

Regarding your request for Notary Public service, insufficient justification was provided 

necessitating Notary Public service. However, you may proceed with an Unsworn Declaration. 

(Signature- Notary) (Date) 

" 
IN THE UNITED STATES DISTRICT COURT 

FOR THE NORbHERN DISTRICT OF TEXAS 

lbt-leth . DIVISION . 

~-#Jq;,rsoq Piail1tiffS ;aJ1diD Number 

J)lck l.Jare,. thz/f . Place ofConfinement 

CASE NO.i I;?LtlQ -I} 

(Clerk will assign the nwnber) 

APPLICATION TO PROCEED 

IN FORMA PAUPERIS 

l, 1Ja/J-;t;_{] uch , declare, depose; and say that l am the Plaintiff in the above entitled case. In support 

of my motion top ed Without bemg reqwred to prepay fees, costs or giVe secunty therefor, I state that because of my 

poverty, I am unable to pay in advance the filing fee for said proceedings or to give security for the filing fee. I believe I am 

entitled to relief. 

I further declare that the responses which I have made to questions and instructions below are true. 

1. Have you received, within the past 12 months, any money from any ofthe following sources? 

2. 

a. Business, profession or form of self-employment? 

b. Rent payments, interest or dividends? 

c. Pensions, annuities or life insurance payments? 

d. Gifts or inheritances? 

e. Family or friends? 

f. Any other sources? 

Yes 0 

Yes 0 

Yes 0 

Yes 0 

Yes 0 

Yes 0 

No~ No LJ/ 

No~ 

No~/ 

No,~·· 

No E:l 

If you answered YES to any of the questions above describe each source of money and state t:he amount 

received from each during the past 12 months. 

. JVIJ! 

Do you own cash, or do you have money in a checking or savings account, including any ftmds in prison 

accounts? 

Yes 0 No~· 

If you answered YES, state the total value of the items owned. 

d/A 

- I -
3. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property, excluding 

ordinary household furnishings and clothing? 

Yes D No~ 

I understand that a false statement or answerto any questions in this affidavit will subject me to penalties for 

perjury. I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct (28 

u.s.c. § 1746). 

Signedthisthe ____ dayof December , 20 /Lf 

-13JJ'!iik.h -IF/9.2~fuq Signature Plamti.ff · 10 Number 

YOU MUST A TI ACH A CURRENT SIX (6) MONTH HISTORYOFYOUR INMATE TRUST 

ACCOUNT. YOU CAN ACQUIRE THE APPROPRIATE INMATE ACCOUNT 

CERTIFICATE FROM THE LAW LIBRARY AT YOUR PRISON UNIT (OR OTHER 

DESIGNATED LOCATION AT YOUR INSTITUTION). 

- 2-
' . gsiN~B02/CINIB02 TEXAS DEPARTMENT OF CRIMINAL JUSTICE ~DW33/PJ00097 IN-FORMA-PAUPERIS DATA 

TDCJ#: 01928809 SID#: 061303~8 LOCATION: WARE TRANSFER 

NAME: BUCK,BOBBY BEGINNING PERIOD: 

12/17/14 

12:24:51 

INDIGENT DTE: 06/06/14 

05/01/14 

PREVIOUS TDCJ NUMBERS: 00920805 01738380 

CURRENT BAL: 0.00 TOT HOLD AMT: 

6MTH DEP: 0.00 6MTH AVG BAL: 

MONTH HIGHEST BALANCE TOTAL DEPOSITS 

10/14 0.00 0.00 

09/14 0.00 0.00 

08/14 0.00 0.00 / 

MONTH 

07/14 

06/14 

05/14 

PROCESS DATE HOLD AMOUNT HOLD DESCRIPTION 

0.00 3MTH TOT 

0.00 6MTH AVG 

HIGHEST BALANCE 

0.00 

0.00 

0.00 

DEP: 

DEP: 

TOTAL 

0.00 

0.00 

DEPOSITS 

0.00 

0.00 

0.00 

STATE OF TEXAS COUNTY OF --'VV, j khe .. Jf 

ON THIS THE .tl_ DAY OF :0eAAbvL /_fj_, I CERTIFY THAT THIS DOCUMENT IS A TRUE, 

COMPLETE,AND UNALTERED COPY MADE BY ME OF INFORMATION CONTAINED IN THE 

COMPUTER DATABASE REGARDING THE OFFENDER'S ACCOUNT. NP SIG: 

PF1-HELP PF3-END ENTER NEXT TDCJ NUMBER: OR SID NUMBER: 

\.. 

,:t~~- rf ,,,,,,,,,--~-

U •' 1-!\Y,. '• JA A ·:-:::o~~'!l=ac:o.::.., ·

1 .~~?>······~ rJIE RUTH PE g ='*!' ::,..n,;: : Notary Public Stat EK ~ 't,.;.., ~l*i My Comml~ 1 

8 Of Texas il --:JI/, .. ~~"4$.~ SEPTfMB .. s on E~lres 

~~QJARY wlR S, 2017 ~THOUTBOND