\AO 240 (Rev. lO/03)

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UNITED STATES DISTRICT CoURT
ncr 3 a 2009

DiSfl'iCf Of COLUMBIA cl€[k n s t _
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(`\@@\4,\,,-,,,\ '/@fz.hm,,,/\ APPLICATIoN To PRoCEED ms
Plaintif`f WITHOUT PREPAYMENT OF
v FEES AND AFFIDAVIT
§   °'c  cAsE NUMBER;   

Defendant

I, NATHAN BRENNAN declare that I am the (check appropriate box)

§§ petitioner/plaintiff/movant ij other

in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
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 under penalty of perjury:
1. Are you currently incarcerated? [Xl Yes lIl No (If "No," go to Part 2)

If "Yes," state the place of your incarceration FCC Yaz°o City) MiSSiSSiPPi
Are you employed at the institution? Yes

Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
transactions.

per mn th)

2. Are you currently employed? § Yes ij No

a. If the answer is "Yes," state the amount of your take-home salary or wages and pay period and give the
name and address of your employer. (List both gross and net salary.)

Approximately $1.82 per month (Institutional employment)

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

3. ln the past 12 twelve months have you received any money from any of the following sources?

a. Business, profession or other self-employment ij Yes [X No
b. Rent payments, interest or dividends El Yes [X No
c. Pensions, annuities or life insurance payments Cl Yes [X No
d. Disability or workers compensation payments l`_`| Yes [X No
e. Gifts or inheritances D§l Yes El No
f. Any other sources E| Yes |Xl No

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If the answer to any of the above is "Yes," descr1be, on the following page, each so ‘Sf ' s e
amount received and what you expect you will continue to receive. SQ,_D q g ,,,t__,.__g
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Do you receive any payment from the institution? Yes §appx $1 . 81

UNITED STATES DISTRICT COURT
FOR THE DIS'I`RIC'I` OF COLUMBIA

CONSENT TO COLLECTION OF FEES FROM TRUST ACCOUNT

R¢; NATHAN BRENNAN v_ DEPARTi"lENT OF JUSTICE
Civil Action No.
I, NATHAN BRENNAN ,Reg.NQ. 57737-019 ,

hereby consent for the appropriate prison official to withhold from my prison account and to pay the
U.S. District Court an initial fee of 20 percent of the greater of:

(a) the average monthly deposits to my account for the six-month period immediately
preceding the filing of my complaint; or

(b) the average monthly balance in my account for the six-month period immediately
preceding the filing of my complaint.

I further consent for the appropriate prison 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 $10.00, the Trust Officer shall forward the interim payment to the
Clerk’s Office, U.S. District Court, until such time as the $250.00 filing fee is paid in ful|.

If appropriate, I will execute the institution consent form where,l am housed, which will
permit the staff to withdraw the amount ordered by this cour,tas ment for the filing fee each
month until the $250.00 filing fee is paid in full. . 

/
J/

By executing this document, l also authorize c<(ction'; on a continuing basis, of any costs
imposed by the District Court, \
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Sigiiaulre of Pla n\tiff
AuguSt 5, 2009
Date

MlM54

FILED

OCT 3 0 2009

Clerk, U.S. District and
bankruptcy Courts

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Pagc 2 of 2

8/5/2()09

