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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&