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0*W U/H//6
IN THE UNITED STATES DISTRICT COURT

FOR THE 1 yd

\Jbto

DISTRICT OF TEXAS

DIVISION

ViWhAL.?* Coam iMvoi

Plaintiff's name and ID Number

W,Q,M<:/W// 0/,1-rPlace of Confinement

case no. flV/6-Oo730-6l/

(Clerk will assign the number)

APPLICATION TO PROCEED

IN FORMA PAUPERIS

^0/iKy< L/ll/yt/^ \Jvu*Ia

Defendant's name and address*'/

I, vl/lM/n MutrtQ (.yrfovi declare, depose, and say I am the Plaintiff in the above entitled case. In support

of my motion to proceed without being required to prepay fees, costs, or give security therefor, I state becauseof 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 the responses which I have made to the questions and instructions below are true.

1. Have'you received, within the last 12 months, any money from any of the following sources?

a. Business, profession or from 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 •

Yes n

Yes H

Yes [J

Yes «

Yes •

No 0"

No H"

No Bf

No U

No •

No H'

If you answered YES to any of the questions above, describe each source of money and state

the amount received from each during the past 12 months.

iLf^iVwA IhJk l.e,<-r 1% \>„>nUf 6{>fx SQ^ 4rTon, fr.. mom f6/AP

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

in prison accounts? ^

Yes T | No •

If you answered YES to any of the questions above, state the total value of the items owned.

•&ATCIFP (REV. 9/02)
Do you own real estate, stocks, bonds, note, automobiles, or other valuable property, excluding

ordinary household furnishings and clothing?

Yes • No a^

If you answered YES, describe the property and state its approximate value.

I understand a false statement in answer to any question in this affidavit will subject me to penalties for

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

(28 U.S.C. §1746).

Signed this the 0<C, day of Uov-en> \>^f ,20 /U.

KV^k?^ j&^ i°miros

Signature of Plaintiff ID Number

YOU MUST ATTACH A CURRENT SIX (6) MONTH HISTORY OF

YOUR INMATE TRUST ACCOUNT. YOU CAN ACQUIRE THE

APPROPRIATE INMATE ACCOUNT CERTIFICATE FROM THE

LAW LD3RARY AT YOUR PRISON UNIT.

•&ATCIFP (REV. 9/02)
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