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                                        IN THE UNITED STATES DISTRICT COURT
                                       FOR THE                      DISTRICT OF TEXAS
                                                                     DIVISION




 Plaintiff's name and ID Number




 Place of Confinement              I


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


                                               /                             APPLICATION TO PROCEED
                                                                                IN FORMA PAUPERIS

Mils n fiotj 3ls iba oci^^> c\oA&m&' *h/ ~7u^o?
 Defendant's name and address            J '              J



            I, C-vtH-JqI -r%~lUt*?Z>C$£zhavQ, 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 •
                   b.     Rent payments, interest or dividends?                               Yes •
                   c.     Pensions, annuities or life insurance payments?                     Yes •
                   d.     Gifts or inheritances?                                              Yes n,
                   e.     Family or friends?                                                  Yes j&j
                   f.     Any other sources?                                                  YesO

                    If you answered YES to any of the questions above, describe each source of money and state
                        amount received from each during the past 12 months.

                 -tzuvuM hir/ \^V\wt tix-in-i:
                                       £0* i tip*
                       a
                    Do you own cash, or do you have money in a checking or savings account, including any funds
                    in prison accounts?
                                                      Yes •            No

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




                                                                                                          &ATCIFP (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




                                                                           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.




                                                                                                  &ATC1FP (REV. 9/02)
CSINIB0S/CINIB02    TEXAS DEPARTMENT OF• CRIMINAL                          JUSTICE                               01/£S/I 5
LM34/AvI85££              IN--FORMA-PAUP ERIS DATA                                                               09 ; Ah9;5|0
TDCJ#: 01811941 3ID#; 03401307 LOCATIONIs MURRAY                                              INDIGENT           DTE:
NAME;    ANDERSON,CHAMEL NICOLE                               BEGINNING    PERIOD;            07/01./14
PREvIOUS          TDCJ    NUMBERS: 01630537
CURRENT       BAL;              IS.01 TOT HOLD         AMT;               <Z>. 00   ;3MTH       TOT     DEP;                    90. 00
6MTH    DEP;       £70.00 6MTH AVG BAL:                                 53.06        «EvMTH     AVG     DEP:                    45. 00
MONTH HIGHEST BALANCE TOTAL DEPOSITS                           MONTH   HIGHEST           BALANCE        TOTAL         DEPOS ITS
1£/14      31. 71          70.00                               09/14         143,a \i /                              40. 00
11/14      13. 98           0. 00                              08/14         1£7., 37                                80. 00
10/14      47. 18          £0.00                               07/14           73,. 94                               60. 00
PROCESS       DATE        HOLD   AMOUNT         HOLD   DESCRIPTION




STATE    OF       TEXAS COUNTY OF_    Qonji\\
ON   THIS     "   HE 2g#)DAY OF C5^jaUQCy_         ?2QiS I CERTIFY THAT THIS DOCUMENT                                      TRUE
COMPLETE, AND            UNALTERED COPY WRDE BY ME OF            INFORMATION CONTftJUMED^JN
COMPUTER          DATABASE    REGARDING     THE    OFFENDER'S     ACCOUNT.          NP    SIG           o?
PF1-HELP          PF3-END    ENTER   NEXT   TDCJ    NUMBER;                  OR      SID      NUMBER;




                                                                                                 ANGELA S.VINCENT
                                                                                                     Notary Public
                                                                                                   STATE OF TEXAS
                                                                                                My Comm. Exp. 02/24/2015
                                                                                          Notary without Bond
