                                     IN THE UNITED STATES DISTRICT COURT
                                   FOR THE /7>>/                   DISTRICT OF TEXAS
                                                  /3*//zs           DIVISION


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Plaintiff's name and ID Number



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Place of Confinement

                                                                                        QS-Of- 0/£66~C/C
                                                                             case No.rO^-^7-- aiss^^r/i
                                                                                     (Clerk will assign the number)
V.


                                                                             APPLICATION TO PROCEED
                                                                                IN FORMA PAUPERIS


                                           ~Z7-
Defendant's name and address
                                                                                                                               II!
                                                                                                        SEP 14 2015
       I, Ulfl/lr&r fflMflid' JCt^Ti;vaeclare. 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 stat®Sfja^|)^fem^|j
poverty, I am unable to pay in advance the filing fee for said proceedings or to give security for the filing fee. I befieve
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 \^
                 b.      Rent payments, interest or dividends?                               Yes •       No \^r
                 c.      Pensions, annuities or life insurance payments?                     Yes •       No H<-
                 d.      Gifts or inheritances?                                              Yes •       No q/
                 e.      Family or friends?                                                  Yes •       No Q/y
                 f.      Any other sources?                                                  Yes •       No Q/

                 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.




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

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




                                                                                                        AATCIFP (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 M

                      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 A^3<aVT cS day of AaSiaSSC                           ,20 iS .


                                      Signature of Plaintiff                       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)
                                             Aa&usY 2£.2m£



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(A)   tdc01bs8 - PASSPORT                              Tuesday,    September 01, 2015, 15:38:36 PM

CSINIB02/CINIB02     TEXAS DEPARTMENT OF CRIMINAL JUSTICE          09/01/15
1BS8/FJ00021               IN-FORMA-PAUPERIS DATA                  15:38:27
TDCJ#: 01.478496 SID#: 07803910 LOCATION: DANIEL          INDIGENT DTE: 01/16/15
NAME: SAGASTUME,WALTER ARNOLD           BEGINNING PERIOD: 03/01/15
PREVIOUS    TDCJ NUMBERS:
CURRENT    BAL:               0.01    TOT   HOLD AMT               0.00       3MTH TOT   DEP:           0, 00
6MTH DEP:                     1.4 7   6MTH AVG BAL                 0.09       6MTH AVG   DEP:           0, 25
MONTH    HIGHEST    BALANCE    TOTAL    DEPOSITS        MONTH    HIGHEST      BALANCE    TOTAL   DEPOSITS
08/15             0 01                  0.00            05/15             0    01                0.00
07/15             0 01                  0.00            04/15             0    01                0.00
06/15             0 ,01                 0.00            03/15             3    16                1.47
PROCESS    DATE      HOLD AMOUNT            HOLD   DESCRIPTION




STATE OF TEXAS COUNTY OF ^CAnf*/
ON THIS THE _[_ DAY OF   t^bC'^~l CERTIFY THAT'                           THIS DOCUMENT IS A TRUE,
COMPLETE,AND UNALTERED^           )PY MADE
                                COPY           BY ME OF INFORMATION CONTAINED IN THE
COMPUTER DATABASE REGARDING THE OFFENDER'S ACCOUNT. NP SIG:
PF1-HELP PF3-END ENTER NEXT TDCJ NUMBER:          OR SID NUMBER:




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