                     UNITED STATES DISTRICT COURT
                     FOR THE DISTRICT OF COLUMBIA


ANTHONY LEWIS,
          PLAINTIFF,


V.                                CASE       NO,



UNTIED STATES OF AMERICA, et al.,
            DEFENDANTS,

          PLAINTIFF'S REQUEST TO PROCEED INEORMA PAUPERIS
       Now comes the plaintiff, Anthony I.ewis, pro-se,

in the above styled cause, and request this honorable court to

grant him leave to proceed in forma pauperis with the litigation

of the present civil action, without prepayment of cost or fee,

given the fact that he is indigent and cannot prepay the cost or

fee upon the filing of the civil complaint.                           The plaintiff has

provided the court a copy of his institutional account in support

of his indigency.

       Wherefore,   the plaintiff request this honorable court

to grant his request for leave to proceed in forma pauperis

with the present civil action, without prepayment of cost or

fee.

                                    Respect^lly Submitted,

                             '^rithony Lewis, Pro~se
                              Reg. NoV 17215-018
                              FCC Coleman-Medium
                              P.O. Box 1032
                              Coleman, Florida 33521-1032




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                                           Mail Room

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                                                                                       Mail Room




                                  A^'jida D. Caesar. Clerk of Co^
                               n S/Ti^lricl rniirl. Dislr"-' "fr.nlumO^-
                                                                                  u 'J.       t Icik of          I
                                                                            S Diainu tourl, Dislrici ofCohimlMi! I
      ^AO240 (Rev. 10/03)                                                  I




                                         United States District Court
                                                             District of       COLUMBIA


           Anthony Lewis,                                          APPLICATION TO PROCEED
                             Plaintiff                             WITHOUT PREPAYMENT OF
                                                                   FEES AND AFFIDAVIT
                               V.


           United States of America, et al. ,
                                                                   CASE NUMBER;
                            Defendant

I, Anthony Lewis                                                         declare that I am the (check appropriate box)
•petitioner/plaintiffmovant/respondent           • other
in the above-entitled proceeding; that insupport of myrequest toproceed without prepayment of fees orcosts
under 28 USC §1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the
relief sought in the complaint/petition/motion.
In support of this application, I answer the following questions underpenalty of peijury:
1. Are you currently incarcerated?                 )lXKYes                  • No             (If"No,"go toPart2)
          If"Yes," state the place ofyour incarceration        FCC Coleman-Medium
          Are you employed at the institution?     Ml.       Do you receive any payment from the institution?              No
      Attach a ledger sheet from the institution(s) of your incarceration showing at least the pastsix months'
      transactions.

      Are you currently employed?                  •   Yes               XE^o
      a       If the answer is "Yes," state the amount ofyour take-home salary or wages and pay period and give the
             name and address of your employer. (List both gross and net salary.)
                                                                  N/A

  b. Ifthe answer is "No," state the date ofyour last employment, the amount ofyour take-home salary or wages
             and pay period and the name and address of your last employer.
                                                             August 1993

  In the past 12 twelve months have you received any money from any ofthe following sources?
  a.        Business, profession or other self-employment            •     Yes           NXKNo
  b.        Rent payments, interest or dividends                     •     Yes           WNo                             Rcom
 c.         Pensions, annuities or life insurance payments          •      Yes           )®Mo
 d.         Disability or workers compensation payments             •      Yes           ^0^0
 e.         Gifts or inheritances                                   •     Yes
 f.         Any other sources                                       •     Yes            Wno
                                                                                                                           L lirk ol t.uuii   ?
                                                                                                 _      S District touft, District orColumhia {
 If the answer to any ofthe above is "Yes," describe, on the following page, each source ofmoney and state the
 amount received and what you expect you will continue to receive.
                                                         N/A
AO 240 (Rev 07/10) Application to Proceed m District Court Without Prepaying Feesor Costs(Short Form)



          4 Amount ofmoney that I have mcash ormachecking orsavings account $                                              N/A
          5 Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or
thing of value that I own, including any item of value held in someone else's name (describe the property anditsapproximate
vqIi^c)
          I have been incarcerated for more than twenty (20) years. I am
          Indigent.




          6 Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe andprovide
the amomt ofthe monthly expense)


                                                                         N/A

                   I do not have any of the above due to incarceration for
                   more than twenty (20) years.

          7 Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship
with each person, and how much I contribute to their support

                                                                         N/A
                 I do not have any of the above due to incarceration for
                more than twenty (20) years.


          8 Any debts or financial obligations (describe the amounts owedand to whom they are payable)




                                                                         N/A
                I do not have any of the above due to incarceraton for
                more than twenty (20) years.

          Declaration I declare under penalty ofperjuiy that the above information is true and understand that a false
statement may result m a dismissal of my claims


Date.
                                                                                    "    / v      /         Applicant s signature



                                                                                                        /      Printed name
InmateStatementCombined                                                                                              Page 1 of2



                                              Inmate Statement
  Inmate Reg #              17215018                              Curient Institution      Colenitin FCC

  Inmate Name               LEWIS ANTHONY                         Housing I nit            COM-B-C

  Report Date               1)8/14/2014                           I iMng Qualtcl^          B05-0I6U

  Report I ime              2 57 17 PM
                                                                                        Transaction    Encumbrance
 Aloha
                       Reference#         Payment#   Receint#   Transaction Tvne           Amount          Amount Endinp Balance
 Code    Date/Time
                       59                                       Sales                        ($7 25)                      $22 49
 CCA     8/14/2014
         1 40 54 PM
 COA     8/14/2014     TFN0814                                  Phone Withdrawal             ($3 00)                      $29 74
         12 06 15 PM
 COA     8/11/2014     TFN0811                                  Phone Withdrawal             (S3 00)                      $32 74
         4 47 22 PM
 COA     8/9/2014      TL0809                                   TRUL Withdrawal              (S5 00)                      $35 74
         9 05 33 AM
 COA     8/7/2014      TL0807                                   TRUL Withdrawal              ($2 00)                      $40 74
         2 16 36 PM
 COA     8/6/2014      64                                       Sales                       ($92 90)                      $42 74
         6 21 08 PM
 COA     8/5/2014      TFN0805                                  Phone Withdrawal             ($7 00)                     $135 64
         6 50 42 PM
 COA     8/3/2014      33314215                                 Western Union               $100 00                      $142 64
         7 06 03 PM
 COA     8/2/2014      TFN0802                                  Phone Withdrawal             ($3 00)                      $42 64
         11 46 11 AM
 COA     7/31/2014     TFN0731                                  Phone Withdrawal             ($5 00)                      $45 64
         5 30 18 PM
 COA     7/31/2014     TL0731                                   TRUL Withdrawal              ($2 00)                      $50 64
         3 11 32 PM
 COA     7/31/2014     TFN0731                                  Phone Withdrawal             ($3 00)                      $52 64
         8 45 03 AM
 COA     7/30/2014     6                                        Sales                       ($10 85)                      $55 64
         12 50 57 PM
 COA     7/30/2014     TL0730                                   TRUL Withdrawal              ($2 00)                      $66 49
         9 58 25 AM
 COA     7/29/2014     TL0729                                   TRUL Withdrawal              ($2 00)                      $68 49
         1 26 25 PM
 COA     7/29/2014     TFN0729                                  Phone Withdrawal             ($5 00)                      $7049
         11 51 51 AM
 COA     7/28/2014     TFN0728                                  Phone Withdrawal             ($3 00)                      $75 49
         5 23 45 PM
 COA     7/28/2014     TL0728                                   TRUL Withdrawal              ($2 00)                      $78 49
         10 00 13 AM
 COA     7/26/2014     TFN0726                                  Phone Withdrawal             ($3 00)                      $80 49
         3 34 07 PM
 COA     7/26/2014     TL0726                                   TRUL Withdrawal              ($2 00)                      $83 49
         9 11 09 AM
 COA     7/25/2014     TFN0725                                  Phone Withdrawal             ($3 00)                      $85 49
         5 03 23 PM
 COA     7/25/2014     TFN0725                                  Phone Withdrawal             ($2 00)                      $88 49
         2 34 49 PM
 COA     7/25/2014     TL0725                                   TRUL Withdrawal              ($2 00)                      $9049
         9 37 04 AM
 COA     7/24/2014     TFN0724                                  Phone Withdrawal             ($3 00)                      $92 49
         8 31 20 PM
 COA     7/23/2014     TFN0723                                  Phone Withdrawal             ($2 00)                      $95 49
         5 06 01 PM
 COA     7/23/2014     11                                       Sales                       ($98 05)                      $97 49
         12 48 17 PM
 COA     7/23/2014     33314204                                 Westem Union                $100 00                      $195 54
         12 06 26 PM
 COA     7/22/2014     TFN0722                                  Phone Withdrawal             ($6 00)                      $95 54
         9 20 51 PM
 COA     7/22/2014     33314203                                 Westem Union                $100 00                      $101 54
         6 07 25 PM
 COA     7/22/2014     TFN0722                                  Phone Withdrawal             ($1 00)                        $1 54
         12 22 44 PM
 COA     7/21/2014     TFN0721                                  Phone Withdrawal             ($1 00)                        $2 54
         10 43 20 AM
 COA     7/21/2014     TL0721                                   TRUL Withdrawal              ($2 00)                        $3 54
         9 52 09 AM




https //lO 33 124 106/truweb/InmateStatementCombined aspx                                                             8/14/2014
ImnateStatementCombined                                                                                                                               Page 2 of2


 COA       7/19/2014       TFN0719                                               Phone Withdrawal                    ($2 00)                               $5 54
           11 33 08 AM
 COA       7/17/2014       40                                                    Sales                           ($54 75)                                  $7 54
           1 30 21 PM
 COA       7/17/2014       TFN07I7                                               Phone Withdrawal                     ($3 00)                             $62 29
           12 30 39 PM
 COA       7/16/2014       TFN0716                                               Phone Withdrawal                     ($2 00)                             $65 29
           5 29 00 PM
 COA       7/16/2014       TFN0716                                               Phone Withdrawal                     ($3 00)                             $67 29
           3 31 42 PM
 COA       7/15/2014       TL0715                                                TRUL Withdrawal                      ($2 00)                             $70 29
           6 1641 AM
 COA       7/14/2014       TFN07I4                                               Phone Withdrawal                     ($3 00)                             $72 29
           8 43 29 PM
 COA       7/14/2014       TFN0714                                               Phone Withdrawal                     ($5 00)                             $75 29
           3 35 22 PM
 COA       7/14/2014       33314195                                              Western Union                        $80 00                              $80 29
           1 08 17 PM
 COA       7/12/2014       TFN0712                                               Phone Withdrawal                     ($1 00)                               $0 29
           12 23 26 PM
 COA       7/11/2014       TFN0711                                               Phone Withdrawal                     ($1 00)                               $I 29
           3 14 02 PM
 COA       7/10/2014       TFN0710                                               Phone Withdrawal                     (SI 00)                               $2 29
           8 02 47 PM
 COA       7/10/2014       TFN0710                                               Phone Withdrawal                     ($I 00)                               $3 29
           10 38 38 AM
 COA       7/9/2014        TFN0709                                               Phone Withdrawal                     ($1 00)                               $4 29
           3 13 45 PM
 COA       7/9/2014        31                                                    Sales                               (S43 40)                               $5 29
           12 03 51 PM
 COA       7/7/2014        TFN0707                                               Phone Withdrawal                     ($3 00)                              $48 69
         12 35 47 PM
 COA     7/7/2014          33314188                                              Western Union                        $50 00                              $5169
         11 08 03 AM
 COA     7/6/2014          TFN0706                                               Phone Withdrawal                     ($1 00)                               $169
         8 50 16 AM
 1 234 5i6 789

                Total Transactions 411

                                                                                                    Totals               ($38 25)             SO 00



                                                                          Current Balances

                         Available     Pre-Release                Debt              SPO             Other     Outstanding        Administrative          Account

  Aloha Code              Balance          Balance       Encumbrance       Encumbrance       Encumbrance       Instruments               Holds           Balance

  COA                      $22 49               $0 00             $0 00            $0 00            $0 00               $0 00             $0 00           $22 49

  Totals                   $22 49               $0 00             $0 00            $0 00            $0 00               $0 00             $0 00           $22 49



                                                                            Other Balances

                                  National 6               NatioanI 6           Local Max                                       Commissarv            Commissarv

           National 6                Months              Months \ \ p     Balance - Prev 30    Averape Balance            Restriction Start       Restriction End

   Months Deoosits              Withdrawals             Dailv Balmce                  Davs       - Prev 30 Davs                       Date                  Date

            $1 925 00               $1,993 40                 $53 85               $195 54                  $57 67                     N/A                   N/A




https //lO 33 124 106/truweb/IiiinateStatementCombined aspx                                                                                            8/14/2014
                                   UNITED STATES DISTRICT COURT
                                   FOR THE DISTRICT OF COLUMBIA




                     CONSENT TO COLLECTION OF FEES FROM TRUST ACCOUNT


  Re         Anthony Lewis                   y United States of America,

  Civil Action No




            I. Anthony Lewis                        # 17215-018               ^
  the appropnate prison official to withhold from my pnson account and to pay the U S Distnct
  Court an initial fee of20 percent of the greater of

            (a)       the average monthlydeposits to my account for the six-month period immediately
                      preceding the filing of my complaint, or

            (b)       the average monthly balance m myaccount for the six-month penod immediately
                      precedmg the filing of my complaint

        I further consent for the appropnate pnson officials to collect from my account on a
 continuing basis each month, an amount equal to 20 percent of each month's income Each time
 the amount in the account reaches $10, theTrust Officer shall forward the intenm payment to the
 Clerk's Office, U S Distnct Court, until such time as the $350 00 filing fee is paid in full

           If appropnate, I will execute the institution consent form where I am housed, which will
permit the staffto withdraw the amount ordered by this court as payment for the filing fee each
month until the $350 00 filmg fee is paid in full

           By executing this document, I also authonze collection, on a continuing basis, anycosts
imposed by the District Court




                                                                         of Plaintiff




n \forms\Trust Account Form
