\     RECEIVEU
        SEP 30 2015                  m THE untje!) STATES DISTRICT COURT
      COURT OF APPEALS    FOR THE                                DISTRICT OF TEXAS
    «WND DISTRICT OF TEW,                                         DIVISION                           pn ,.
    SDEBRASP1SAK, CLERK                                                                  SeCg$*To^p
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Plaintiff's name and ID Number
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Place of Confinement                                    '       ~7$?8H                                          **

                                                                            CASENO. ^I^^r-C
                                                                                         (Clerk will assign the number)


     DlVfv^           »      „ I-       /x    ^ \      ,\ o       ,htv APPLICATION TO PROCEED
     tOV**- oatsfbliCt 0^>C-4rn«i^fovv644lX.                                     IN FORMA PAUPERIS

Defendant's name and address




      I, nrrn^tf (jgJfiGrl 6 Cffi-. declare, depose, and say I am the Plaintiff in the above entitled case. In support
ofmy motion to proceed wrdiout being required to prepay fees, costs, or give security therefor, I state because ofmy
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?                       Yes Q          No 5fl.
                 b.      Rent payments, interest or dividends?.                              Yes •          No So
                 c. Pensions, annuities or life insurance payments?                          Yes •          No 0j
                 d. Gifts or inheritances?                                                   Yes •          No 0
                 e. Family or friends?                                                       Yes f\jf       No Q .
                 f. Anyother sources?                                                        Yes •          No \$/
                 If you answeredYES to any of the questions above, describe each source of money and state
                 the amount received from each during the past 12 months.

                               '-f


        2.       Do you own cash, or do you have money in a checking or savings account, including any funds
                 in prison accounts?                        t
                                                    Yes 0           No D

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




                                                                                                            rATCIFP (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

               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       ^^          dav of o<jp r<u^ o€/*"               ,20 \$_.


                               Signature ofPlaintiff u         7            ID Number
