(..`._~_;)' n ," IN THE UNITED STATES DISTRICT COURT

4 § ~ _. § FoR THE 92 DISTRICT oFTEXAs
_ , j ' 1_ D_IvlsloN

 

 

 

CO RECEll/ED IN
\k.a\m\k \,1 11 (@1”3?)°3'5 ’ , URT °FCR"""NALAPPEALS
Pl iff’ d h
aint s name ah ID Number AUG 2 0 ZMS
1111 /:1%111111111% 1 11 11 1 511 .
Place of Confinement 1. . ., . A@@!AC@SM,CH@FK
CASE NO. ‘ §
(Clerk will assign the`number)
v. 4 , 1
A1¥1>LICAT10N'T0 PRocEEp
IN FORMA PAUPERIS

    

1 Defenda t’ s name and address

1 111

 

,declare, depose, and say I arn the Plaintiff in the above entitled case. In support

j of my motion to proceed witho t 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 th`e filing fee. I believe l

am entitled to relief.

l, further declare the responses which I have made to the questions and instructions below are true.

.NO §

`NOM

No g
No[Z]"

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 |:I
4 l b. Rent payments, interest or dividends? § Yes []
c. Pensions, annuities or life insurance payments? l Yes l:\
d. Gifts or inheritances? ' . Yes [l
e.` -Family or friends? ' ~' Yes l'~_?]/
f. Any other sources? ~ ~' ` ' - Yes []

N§§/

'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.

     
 

.\¥\1\~1 \Qas. as l

 

in prison accounts? _ E{
Yes - \:\ No

Do you own cash, or do you have money in a checking or savings account, mc u lng any nds

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

 

 

rkATCIFP (REV. 9/02)

_,'" 3. Do you own real est'ate, stocks, bonds, note, automobiles, or other valuable property, excluding
4 ‘ l ordinary household furnishings and clothing? E{
No

Yes []

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).

 

 

 

n Signed this the l L…\ `/\. day of A\Ao\u§“l . l ., 20 \3 .
1/%]1/,,1/&{%1@/ //)‘{3 533
Signature of Plaint§iff ID Number

YOU M___UST A'I'I`A_CH A CURRENT SIX (6) MONTH HISTORY OF
YOUR INMATE TRUST ACCOUNT. YOU CAN ACQUIRE THE

_APPROPRIATE INMATE ACCOUNT CERTlFICATE FROM THE
LAW LIBRARY AT YOUR PRISON UNIT.

2 ' ' ' l aATcIFP(REv. 9/02)

