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                                        IN THE UNITED S 1\TES DISTRICT COURT
                                       FOR THE          m-"CDISTRICT OF TEXJ\S
                                                 ~<.......=.:~-=-.:cJ,~rJ~DIVISION


          Wa.[Gr: rJ. (}, met!SS3 'I'll
    Plaintiff's name and ID Number


      Goree UfJiJ;Ifuri17Svr1t, 7l
    Place of Confinement


                                                                               CASE N O · - - - . . , . - - - - - - -
                                                                                      (Clerk will assign the number)
    v.
                                                                               1\PPLICJ\TION TO PROCEED
                                                                                   IN FORMJ\ Pl\UPERIS


    Defendant's name and address



             I, \tJa~~~      f3
                              r   Wrv112T,   declare, depose, and say I am the Plaintiff in the above entitled case. In suppo.rt
    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 madeto 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 0       No t2(
                     b. Rent payments, interest or dividends?                                    Yes 0       NoM"
                     c. · Pensions, annuities or life insurance payments?                        Yes~        No 0
                     d. Gifts or inheritances?                                                   Yes 0       NoW
                     e. Family or friends?                                                       Yes 0       No~
                     f. Any other sources?                                                       Yes 0       No gi

                     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.

                      $ &13 IJ.cl&<Archt o-r4 ~T I;L M~-
                                   I

              2.      Do you own cash, or do you have money in a checking or savings account, including any funds
                      in prison accounts?
                                                    Yes ·E!         No 0

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

                      {Jrr~ 501/J Tr:usTaccoociJL"                (Y2vTS!OIIJ     ha.fa VIce. J /0, '177

                                                                                                            i?ATCIFP (REV. 9/02)
 i. .~··   '··•·




           3.       Do you own real estate, stocks, bonds, note, automobiles, or other valuable property, excluding
                    ordinary household furnishings and clothing?

                                                             Yes D             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 -------'2'-=---=3=--J'-__day of   _0_-=----=~==------=--------===---' 20 f tf.
                                         cuaJti s.
                                       Signature of Plaintiff
                                                                      ~-;SJJ7tcfr
                                                                                            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.




                                                                         2                                  t:rATCIFP (REV. 9/02)
CSINIB02/CINIB02              TEXAS DEPARTMENT OF CRIMINAL JUSTICE                                            1i~~/i.~3/l·4
(31~25 I BI...J I~                           I N·-FO f~i¥1A-·-P!=-1lJPE F~ IS Dr::rr(-~i                      12 : s:.s : IZII(.)
TDCJ#: 01553441 SID#: 07749477 LOCATION: GOREE                                                       INDIGENT DTE~
NAME: CORNET~WALTER                                                  BEGINNING PEI~IOD: tZI5/tZl1 /itt
PREVIOUS TDCJ NUMBERS~
CUI~I~ENT BAL:                 ~5 .. .t.,.c; TOT HOL.D ~~ttiT u                          0.00 3MTH TOT DEP~                   145.44
6M1H DEPu                    242.40 6MfH AVG BAL:                                     16.34 GMTH AVG DEP:                         40.40
MONTH HIGH~ST BALANCE TOTAL DEPOSITS                                    MONfH HIGHEST BALANCE TOTAL DEPOSITS
                                               tl-(3. L~e,              tZI7 I l LJ.                            96 . 96
~~9 / 1 Lt.       1+6 • 31                     t+E~. ~.,.s              06/1 Lt.             ill. 33             0. tZI0
IZiB/1 ,,.        46" f.t·7                    48.48                    05/14                IL~. 33             IZI. QIIZI
PROCESS DATE             HOLD AMOUNT                  HOLD DESCRIPTION




f.·3TATC m-:· TCX:~s r:ouNTY OF           Wo..l ke.r
ON THIS TI-IE~3~i:ly OF Oe.ee-;;/2_;;;_~~-~0/..lf I CERTIFY TH~lT THIS DOCUMEt"-H IS f-i TRUE,
COMPL~TE,AND UNALTERED COPY MADE BY ME OF INFORMATION CONTAINED IN THE
COMPUTER DATABASE REGARDING THE OFF~NDER'S ACCOUNT. NP BIG:
PF1-HELP PF3-END ENTER NEXT TDCJ NUMBER:                        OR SID NUMBER:




                             .....
