Court Opinion

ID: 4051710
Source: CourtListenerOpinion
Date Created: 2016-09-29 01:45:13.289243+00
Date Added: 2024-06-11T14:31:22.310446
License: Public Domain

IN THE UNITED STATES DISTRICT COURT
                                   FOR THE /7>>/                   DISTRICT OF TEXAS
                                                  /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

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

                                                                             APPLICATION TO PROCEED
                                                                                IN FORMA PAUPERIS

                                           ~Z7-
Defendant's name and address
                                                                                                                               II!
                                                                                                        SEP 14 2015
       I, Ulfl/lr&r fflMflid' JCt^Ti;vaeclare. 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 stat®Sfja^|)^fem^|j
poverty, I am unable to pay in advance the filing fee for said proceedings 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?                       Yes •       No \^
                 b.      Rent payments, interest or dividends?                               Yes •       No \^r
                 c.      Pensions, annuities or life insurance payments?                     Yes •       No H<-
                 d.      Gifts or inheritances?                                              Yes •       No q/
                 e.      Family or friends?                                                  Yes •       No Q/y
                 f.      Any other sources?                                                  Yes •       No Q/

                 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.

        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)
    /          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 of perjury that the foregoing is true and correct
        (28 U.S.C. §1746).

               Signed this the A^3