, o 50 1 s : 29199 -067 : . _____REGEIVED
‘Name and Plisoner/Booking Number : 7 . re 2 7

FILED. LODGED,
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US. Peatheuttavy Tues ele aan
Place of Confinement — - MAR 12 2018 '- aa
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Mailing Adress oo py COSTREP GE ASEONA

Treson. AZSS THB:

City, State, Zip Code

IN THE UNITED STATES DISTRICT COURT

ee 0136 TUCCKIPSOT
ane Henan 6-8 ovo,

)
vs. ) APPLICATION TO PROCEED
) INFORMA PAUPERIS-
M. Bacon, er ah. ) BY A PRISONER
Defendant(s)..—) CIVIL (NON-HABEAS)
) .

I, Gorge Ochre i fase0 _, declare, in support of my request to proceed in the above

: entitled case without prepayment of fees under 28 U.S.C. § 1915, that I am unable to pay the fees for these.
proceedings or to give security therefor and that I believe Iam entitled to-relief.

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

i: Have you ever before brought an action or appeal in a federal court while you were incarcerated or detained?

Dyes. RNo If "Yes," how many have you filed?
Were. any of the actions or appeals dismissed because they were frivolous, malicious, or failed to state a

claim upon which relief may be granted? Ovyes RNo If" Yes," how many-of them?

2. Are you currently employed at tthe institution where you are confined? Byes. ONo
If "Yes," state the amount of your pay and where you work. _ ‘Ss wroataley
3. Do you receive any other payments from the institution where you are confined? Oyes No

If "Yes," state the source and amount of the payments.

Revised 4/9/06


_4.- Do you have any other sources of income, savirigs, of assets either inside or outside of the institution where

Oyes [SNo.

you are confined? .
If "Yes," state the sources ‘and amounts of. thei income, savings, or assets.

. I declare under penalty of perjury that the above information i is true and correct. .

361g od SUT — ;
DATE ; : } SIGN, | OF APPLICANT *

CONSENT TO COLLECTION OF FEES. FROM TRUST ACCOUNT

‘ 2) hereby consent'to having the designated correctional officials at this
institution release to the Court-my trust account information. .:I further consent to having the designated
correctional officials at this institution withdraw from my trust account the funds required to comply with th the

order of this Court for the payment of filing fees in-accordance with 28 U.S.C. § 1915(b). ©
My consent includes withdrawal from my account by‘ correctional’ officials of partial initial payments to this

Court equal to 20% of the greater’ of:
. (A) - the average monthly deposits to my a account for the ‘six-month period preceding my filing of this

action, or
(B) the average monthly balance in my accotint for the six-month period preceding my filing of this

action. .
My consentalso includes monthly withdrawals from my account by correctional officials ofan amount equal
* to 20% of each month’s income. Whenever the amourit in my account. reaches $10.00, correctional officials will
‘withdraw that amount and forward it to the Court until the required filing fee is paid in full. I understand that I
* am liable for paying the entire fee, even if my case is dismissed by the Court before the fee is fully paid.

3-b-18

"DATE SIGNATYRE QF ARPLICANT

CERTIFICATE. OF CORRECTIONAL OFFICIAL
AS TO STATUS OF APPLICANT’S TRUST ACCOUNT

Sole, certify that as of the date applicant signed this application:

. (Printed name of official) .
The applicant’s_trust account balance at this institution is: _$ la >. O _ :
The applicant’s average monthly deposits during the prior six.months is: “ $ 1-66
$.

The applicant’s average monthly balance during the’ prior six months is:

The attached VEC reflects the status of the applicants account.
EAM fi TM ; Ce. USP tucson,

“DATE AGTHORIZED SIGNAPORE TITLED NUMBER INSTITUTION

Revised 4/9106

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