                                  IN THE UNITED STATES DISTRICT COURT
                                FOR THE /7/v/                    DISTRICT OF TEXAS
                                              /3*//<!ZS            DIVISION


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Plaintiff's name and ID Number




Place of Confinement

                                                                                          0S-O7- o/£66-C/£
                                                                           CASE NO. <0 £~-4 7- Z?/^ 5 <? -r/l
                                                                                    (Clerk will assign the number)
V.


                                                                           APPLICATION TO PROCEED
                                                                              IN FORMA PAUPERIS



Defendant's name and address
                                                                                                           wyfH


                                                                                                  SEP 14 2015
        I, Ulfl/lrEf mMn&d 3ft&WVaeclare. 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 sta<
poverty, I am unable to pay in advance the filing fee for said proceedings or to give security for the filing fee. I believe
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 [y
                b.   Rent payments, interest or dividends?                                       Yes   •      No Q^
                c.   Pensions, annuities or life insurance payments?                             Yes   •      No B^
                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)
               Do you own real estate, stocks, bonds, note, automobiles, or other valuable property, excluding
               ordinary household furnishings and clothing?

                                                Yes •           No gT

               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   vU5u.fJrSdav of kkS^s)r                             _, 20 15


                                                                                   Mint,
                               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.




                                                                                                  T^rATCIFP (REV. 9/02)
                                                  Aaa>us>Y 2B.Zm£




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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:                  1.47   6MTH AVG BAL                 0.0 9    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
ON THIS THE J_ DAY OF jfrfl-fe^ \fT, fcTI CERTIFY THAT THIS DOCUMENT IS A TRUE,
COMPLETE,AND UNALTERED COPY MADE 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:
