(..`._~_;)' n ," IN THE UNITED STATES DISTRICT COURT
4 § ~ _. § FoR THE 92 DISTRICT oFTEXAs
_ , j ' 1_ D_IvlsloN
CO RECEll/ED IN
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Pl iff’ d h
aint s name ah ID Number AUG 2 0 ZMS
1111 /:1%111111111% 1 11 11 1 511 .
Place of Confinement 1. . ., . A@@!AC@SM,CH@FK
CASE NO. ‘ §
(Clerk will assign the`number)
v. 4 , 1
A1¥1>LICAT10N'T0 PRocEEp
IN FORMA PAUPERIS
1 Defenda t’ s name and address
1 111
,declare, depose, and say I arn the Plaintiff in the above entitled case. In support
j of my motion to proceed witho t 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 th`e filing fee. I believe l
am entitled to relief.
l, further declare the responses which I have made to the questions and instructions below are true.
.NO §
`NOM
No g
No[Z]"
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 |:I
4 l b. Rent payments, interest or dividends? § Yes []
c. Pensions, annuities or life insurance payments? l Yes l:\
d. Gifts or inheritances? ' . Yes [l
e.` -Family or friends? ' ~' Yes l'~_?]/
f. Any other sources? ~ ~' ` ' - Yes []
N§§/
'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.
.\¥\1\~1 \Qas. as l
in prison accounts? _ E{
Yes - \:\ No
Do you own cash, or do you have money in a checking or savings account, mc u lng any nds
If you answered YES to any of the questions above, state the total value of the items owned.
rkATCIFP (REV. 9/02)
_,'" 3. Do you own real est'ate, stocks, bonds, note, automobiles, or other valuable property, excluding
4 ‘ l ordinary household furnishings and clothing? E{
No
Yes []
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).
n Signed this the l L…\ `/\. day of A\Ao\u§“l . l ., 20 \3 .
1/%]1/,,1/&{%1@/ //)‘{3 533
Signature of Plaint§iff ID Number
YOU M___UST A'I'I`A_CH A CURRENT SIX (6) MONTH HISTORY OF
YOUR INMATE TRUST ACCOUNT. YOU CAN ACQUIRE THE
_APPROPRIATE INMATE ACCOUNT CERTlFICATE FROM THE
LAW LIBRARY AT YOUR PRISON UNIT.
2 ' ' ' l aATcIFP(REv. 9/02)