Cornet, Walter

Court: Court of Appeals of Texas
Date filed: 2015-01-02
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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&