IN THE UNITED STATES DISTRICT COURT 

### FOR THE /7>>/ DISTRICTOFTEXAS /3*//zs DIVISION 

# \)/AWr hf(\o\f\rs ftd/tasWi^ff' M78Mb Plaintiff's name and ID Number 

# 9f\LL DQJnd UffiV Place of Confinement

V. 

## QS-Of- 0/£66~C/C
case No.rO^-^7-- aiss^^r/i (Clerk will assign the number)

Defendant's name and address ~Z7- APPLICATION TO PROCEED IN FORMA PAUPERIS



## SEP 14 2015 

## I, Ulfl/lr&r fflMflid' JCt^Ti;vaeclare. depose, andsayIamthePlaintiffintheaboveentitledcase. In support ofmy motiontoproceedwithoutbeingrequiredtoprepayfees, costs, orgive securitytherefor, Istat®Sfja^|)^fem^|j poverty, I amunable to pay in advance the filing fee for saidproceedings or to give security for the filing fee. I befieve
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 • Yes • Yes • Yes • Yes • 

# No \^ No \^r 

## No H<- No q/ 

## No Q/y No Q/ 

### If youanswered YES to any of thequestions above, describe each source ofmoney and state the amount received from each during the past 12 months.



### 2. Do you own cash, or do you have money in a checking or savings account, including any funds in prison accounts? . Yes • No M If you answered YES to any of the questions above, state the total value of the items owned.

AATCIFP (REV. 9/02) 

### II!

### / 3. Do you own real estate, stocks, bonds, note, automobiles, or other valuable property, excluding £ ordinary household furnishings and clothing?
Yes • No M 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 ofperjury that the foregoing is true and correct (28 U.S.C. §1746). 

# Signedthisthe A^3<aVTcSdayof AaSiaSSC ,20 iS .

Signature ofPlaintiff 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 LIBRARY AT YOUR PRISON UNIT.

•&ATCIFP (REV. 9/02)

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- PASSPORT 

### Tuesday, September 01, 2015, 15:38:36 PM CSINIB02/CINIB02 TEXAS DEPARTMENT OF CRIMINAL JUSTICE 1BS8/FJ00021 IN-FORMA-PAUPERIS DATA TDCJ#: 01.478496 SID#: 07803910 LOCATION: DANIEL INDIGENT 03/01/15 09/01/15 15:38:27 DTE: 01/16/15 NAME: SAGASTUME,WALTER ARNOLD PREVIOUS TDCJ NUMBERS:0.01 TOT HOLD AMT 1.4 7 6MTH AVG BAL BALANCE TOTAL 01 01 ,01 HOLD AMOUNT BEGINNING PERIOD:

CURRENT BAL: 6MTH DEP: MONTH HIGHEST 08/15 0 07/15 0 06/15 0 PROCESS DATE 0.00 3MTH TOT DEP: 0.09 6MTH AVG DEP: HIGHEST BALANCE TOTAL DEPOSITS MONTH 0.00 05/15 0.00 04/15 0.00 03/15 HOLD DESCRIPTION 0 0 3 01 01 16 0, 0, DEPOSITS 0.00 0.00 1.47



# STATE OF TEXAS COUNTY OF ^CAnf*/ t^bC'^~l CERTIFY THAT' ON THIS THE _[_ DAY OF COMPLETE,AND UNALTERED^ COPY THIS DOCUMENT IS A TRUE, )PY 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:



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