                                      Texas Court of Criminal Appeals                        ^OURT op
                                    P.O. Box 12308 Austin Texas 78711                                         '•APPEALS
                                                                                                     SEP 08 2015
                                      "In re Eric Flores , pro se relator"

                                     "In re The State of Texas , relator"

                                                                vs.



                                   Richard James Rick Perry , defendant

                  APPLICATION TO PROCEED INFORMA PAUPERIS ON
                  APPEALWITHOUT HAVING TO PREPAY FILEING FEES


 Affidavit in Support of the Application                        Instructions


 I am a plaintiff or petitioner in this case and declare        Complete all questions in this application and then sign it.
 that I am unable to pay the costs of these proceedings         Do not leave any blanks: ifthe answer to a question is "0,"
 and that I am entitled to the relief requested. I declare      "none," or "not applicable (N/A)," write that response. If
 under penalty of perjury that the information below is         you need more space to answer a question or to explain your
 true and understand that a false statement                     answer, attach a separate sheet of paper identified with your
 a dismissal ofmy ^                                             name, your case's docket number, and the question number.

 Signed:                                                        Date:



1.      , For both you and your spouse estimate the average amount of money received from each ofthe following
          sources during the past 12 months. Adjust any amount that was received weekly, biweekly, quarterly,
          semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions
         for taxes or otherwise.

                  Income source                              Average monthly income             Income amount expected
                                                             amount during the past 12                   next month
                                                                          months
                                                               You                 Spouse          You             Spouse
Employment

Self-employment
                                                      $ O
Income from real property (such as rental income)
                                                      $o                     $ e::)         %C /O
Interest and dividends
                                                      sC25                   s              sQ ^
Gifts
                                                                             « CZi          $ d^'-             $ 03
Alimony
                                                      sQ
Child support
                                                                      ^      s              sc:5>                           A
                                                                                                                                        Page 2 of 5

AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)

Retirement (such as social security, pensions, annuities,
                                                                  $                                          $
insurance)
Disability (such as socialsecurity, insurance payments)
                                                                  $ ^                     $

Unemployment payments
                                                                  $
Public-assistance (such as welfare)
                                                                  s CT
Other (specify)'.
                                                                  $
                                                                                          •<27
                                 Total monthly income:
                                                                  $C^^^0.00                                                                   0.00



2.        List your employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or
          other deductions.)

Employer                             Address                                               l       Dates of employment            T (^ross
                                                                                                                                  mgirtjMy.pay


                                             a/
                                             ECZS
3.        List your spouse's employment history for the past two years, most recent employer first. (Gross monthly pay is before
        . taxes or other deductions.)          ^
Employer                             Address                                                       Dates of employment                Gross
                                                                                                                                  monthly pay

                                                                                                                                  $



                                                                                                                         b


                          a
                                                                                                                             o




4.        How much cash do you and your spouse have? $
          Below, state any money you or your spouse have in bank accounts or in any other financial institution.
Financial institution                          Type of account                                    Amount you have                Amount your
                                                                                                                                  spouse has

                     /A                                    \s i/'i\
                                                           k r/A                          $                              $



-4 MViHr                                                N'/fr $                                            Cjr           $ Ob
If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts,
expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts,
perhaps because you have been in multiple institutions, attach one certified statement of each account.
                                                                                                                                   Page 3 of 5

AO 239 (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)

5.        List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary
          household furnishings.

                                                      Assets owned by you or your spouse


Home (Value)

Other real estate (Value)


Motor vehicle #1 (Value)

                   Make and year:

                   Model:


                   Registration #:

Motor vehicle #2 (Value)

                   Make and year:

                   Model:


                   Registration #:

Other assets (Valm)

Other assets (Value)


6.        State every person, business, or organization owing you or your spouse money, and the amount owed.
Person owing you or your spouse                            Amount owed to you                              Amount owed to your spouse
money


                                               •             r::?
                                               •             <^7^
           i\l /A                               •

7.         State the persons who rely on you or your spouse for support.
Name (or, if under 18, initials only)                                        Relationship                                       Age
                                                                               V                            ,




               j             '
                                                                               \             19/?A \4rO^                              ^ c-
                                                                                                                        Page 4 of 5

AO 239 (Rev. 01/15) Application to Proceed in District Court Witliout Prepaying Fees or Costs (Long Form)

          Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your
          spouse. Adjust any payments that are made weekly, biweekly, quarterly, semiannually, or annually to show the
          monthly rate.

                                                                                                            You   Your spouse

Rent or home-mortgage payment (including lotrentedJbr mobile home)
          Are real estate taxes included? • Yes ^No
          Is property insurance included? • Yes I^TNo
Utilities (electricity, heatingfuel, water, sewer, and telephone)

Home maintenance (repairs and upkeep)

Food


Clothing

Laundiy and diy-cleaning

Medical and dental expenses

Transportation (not including motor vehicle payments)

Recreation, entertainment, newspapers, magazines, etc.
                                                                                                                       7
Insurance (not deductedfrom wages or includedin mortgagepayments)

          Homeowner's or renter's:


          Life:


          Health:


          Motor vehicle:


          Other:

Taxes (not deductedfrom wages or included in mortgagepayments) (specify):


Installment payments

          Motor vehicle:


          Credit card (name):

          Department store (name):

          Other:


Alimony, maintenance, and support paid to others
                                                                                                                     Page 5 of 5

AO 239' (Rev. 01/15) Application to Proceed in District Court Without Prepaying Fees or Costs (Long Form)


Regular expenses for operation of business, profession, or farm (attach detailed
statement)

Other (specify)'.


                                                                        Total monthly expenses:
                                                                                                                $   ^ ^ 0.00
9.        Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the
          next 12 months?

          •   Yes        ^^o               Ifyes, describe on an attached sheet.
10.                        51^11
          Have you spent — or "^11 you be spending— any money for expenses or attorney fees in conjunction with this
           lawsuit?      •   Yes      ^o
          If yes, how much?           $

11.       Provide any other information that will help explain why you cannot pay the costs of these proceedings.

                                                                                                            d
12.       Identify the city and state of your legal residence.



          Your daytime phone number:                       ^ 1^           (-^ I           Qp
          Your age:                       Your years ofschooling:                            CT ^
