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                                           /RECEIVEDN
                                                JAN 0 4 2017
                                           "vTHiRD COURT OF APPEALS )
                                            \_JFTOYAKYtE_/
LSiNiB0£/ClNIB0E            TEXAS DEPARTMENT OF CRIMINAL JUSTICE                                                   12/27/16
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 'DC J# ; 01 163 :l 01 31 D# :; 05925934 LOCATI ON s ELL IG                                              INDI GENT DTE :
'AME:; BRUGMANN, MICHAEL TERRY                                         BEGINNING PERIOD:: 06/3:1/16
;• REV IOUS   TDC J   MUMBERG ::
CURRENT BAL:;        146,. £1 TOT HOLD ANT;                                         8,. 00       3MTH      TOT        DEP;:            150. C
NTT'H DEP;;          350.013 6 NTH AUG BAL.:                                       '54-84        6 NTH     PUG        DEP::             53.. 3
NGMTH HIGHEST BALANCE TOTPL DEPOSITS                                    MONTH    HIGHEST            BALANCE           TOTAL DEPOSITS
i i / 1S    10S. 3 £           5 0, 0 0                        0 8/16                    3.0 4 . 1 1                      :!. 0 0, 0 0
•0/16        77.95             50.00                           07/16                      50.. 13                             50„ 00
^9/16            78.. 73                         50„ 00        06/16                       63.37                                 50,00
PROCESS       DATE      HOLD    ftMOUNT              HOLD DESCRIPTION




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                             M. SCHANFISH                  ?
                       W   N°tary Public. State of Texas °
                             My Commission Expires         e
                                    10-27-2017             0
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                      Notary Without Bond




                                                                                                                       RECEIVED^

                                                                                                                  JHIRDC0UR70FAPPEALS J
                                    IN THE UNITED STATES DISTRICT COURT
                                   FOR THE   W         DISTRICT OF TEXAS
                                                        DIVISION
                                               3f C<nu»t~ ^4 fyp*a(; /9ujh0/-m
     /Iruj/n*/)/) /n/rA^s / Tlcrr*
  aintiff's
Plainti        name and ID Number

      e/l« / foil M^ottbT*. -7-73W
Place of Confinefhent


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

                                                                             APPLICATION TO PROCEED
                                                                                IN FORMA PAUPERIS



Defendant's name and address




          ViWchatl 7iftu &u&*t6»^           , declare, depose, and say I am the Plaintiff in the above entitled case. In support
ofmy motion to proceed without being required toprepay fees, costs, orgive 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 [ET
                   b. Rent payments, interest or dividends?                                    Yes •       No \Pf
                   c.    Pensions, annuities or life insurance payments?                       Yes •       No \Df
                   d. Gifts or inheritances?                                                   Yes •       No 0^
                   e. Family or friends?                                                       Yes |g)     No •
                   f. Any other sources?                                                       Yes D       No df

                   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.

                   rfb-fhlr S/'/utrS'o,0* s/o//AfS a. /y>omk6u>tf/eo,*0c'a//Arj £r CAstrU^r wASrfrtJy

          2.       Do you own cash, ordo you have money in a checking orsavings account, including any funaS k'vcD \
                   in prison accounts?                                                                        1 Mqa ?nI7
                                                     Yes [2           No D                                    I              U,/
                                                                                                              \TH'R?C0l/RrOFAPPEAL
                   If you answered YES to any of the questions above, state the total value of the items ownedi«i£SsY (!KV£__,




                                                                                                          -&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 0^
              If you answered YES, describethe 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    <2? K         dav of Z>ect*6tr-                   , 20 /£ .



                              Signature of Plaifitiff ^                    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)
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