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                        a<?^   ^
                                    IN THE UNITED STATES DISTRICT COURT
                                  FOR THE                     3 DISTRICT OF TEXAS
                                                                ^DIVISION



Plaintiff's name and ID Number




Pl&e ofConfinement> ;                 ~^.         Q

                                                                           CASE NO.
                                                                                        (Clerk will assign the number)
V.


                                                                           APPLICATION TO PROCEED
                                                                              IN FORMA PAUPERIS



Defendant's name and address




         I, X)aSC-l\k \-te>\0ic C4t , 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 because of 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?                            Yes •        No 0/-
                 b. Rent payments, interest ordividends?                                     Yes •        No ET/
                 c. Pensions, annuities orlife insurance payments?                           Yes •        No S^S
                 d.      Gifts or inheritances?                                              Yes •        No 0^
                 e.      Family or friends?                                                  Yes •        No FT
                 f.      Any other sources?                                                  Yes •        No FT

                  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.




                  Do you own cash, or do you have money in a checking or savings account, including any funds
                  in prison accounts?                                     /
                                                      Yes •          No 1%/
                  If you answered YES to any of the questions above, statethe 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 &

              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 3 \ [%            day of iM {if AW                    ,20 [&

                                  Dr,0 ®$T^~
                               Signature of Plaintiff
                                                                      \-nVJ9f!
                                                                           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)
CSINIBOS/CINIB02              TEXAS      DEPARTMENT       OF    CRIMINAL    JUSTICE                                 ©4/01/15
LH30/SRA6141                             IN-FORMA-PAUPERIS DATA                                                     13:48:40
TDCJ#:    01273988        SID#s    06630035      LOCATIONS       JAMES    LYNAUGH          INDIGENT                 DTEs       11/07/14
NAME:    ROBERTS,.DARRELL                                      BEGINNING PERIOD:           10/01/14
PREVIOUS       TDCJ   NUMBERS:
CURRENT    BALs                   0.70   TOT   HOLD     AMT:             50.00     3MTH        TOT           DEPs                      0. 70
6MTH    DEPs                  30.70 6MTH         flVG   BAL:               0.34 6MTH           AVG           DEP:
MONTH    HIGHEST      BALANCE      TOTAL DEPOSITS               MONTH    HIGHEST       BALANCE               TOTAL         DEPOSITS
03/15             0.70                     0.00                 IS/14             0.00                                     0.00
02/15             0.70                     0.00                 11/14         30.00                                    50. 00
01/15             0.70                     0.70                 10/14             0.00                                     0. 00
PROCESS    DATE        HOLD   AMOUNT           HOLD     DESCRIPTION




STATE OF TEXAS COUNTY OF Peaf*
ON THIS THE J_ DAY OF &££,                        , ££,   I CERTIFY THAT THIS DOCUMENT IS A TRUE,
COMPLETE,AND UNALTERED COPY MADE BY ME OF INFORMATION CONTAINED IN THE
COMPUTER       DATABASE     REGARDING      THE    OFFENDER'S       ACCOUNT.       NP   SIGs
PF1-HELP       PF3--END    ENTER    NEXT   TDCJ    NUMBER:                   OR    SLBHMUMBER:




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                                                                                                     SAWU6L G.                     »

                                                                              mi               Motiry Public. State «' Texas «
                                                                                                   My Commissi"'! Expires
                                                                                                              03 21 201*
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