P.D^SoX \9vSO? Co.Oi(^l+ SMztTuart «i3?nie Oc^nr &rs or M.4m^ ***o*(*m C VxtLOt uonM\ fcO-feuT IVtw ft Irk*. iDofk-iACju fico - S*~~ & hfiu)C b*L \xoiLfI supervisory pD^r -fo ^ak^iUfL lo F i 4>Mlu-if^^ 4d( ol aoo& rtpor Oottk ^ac Q<-A«£ af^ce/ tfuJolm ; ~^. Q CASE NO. (Clerk will assign the number) V. APPLICATION TO PROCEED IN FORMA PAUPERIS Defendant's name and address I, X)aSC-l\k \-te>\0ic C4t , declare, 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 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 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 0/- b. Rent payments, interest ordividends? Yes • No ET/ c. Pensions, annuities orlife insurance payments? Yes • No S^S d. Gifts or inheritances? Yes • No 0^ e. Family or friends? Yes • No FT f. Any other sources? Yes • No FT 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. Do you own cash, or do you have money in a checking or savings account, including any funds in prison accounts? / Yes • No 1%/ If you answered YES to any of the questions above, statethe total value of the items owned. •&ATCIFP (REV. 9/02) Do you own real estate, stocks, bonds, note, automobiles, or other valuable property, excluding ordinary household furnishings and clothing? Yes • No & 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 3 \ [% day of iM {if AW ,20 [& Dr,0 ®$T^~ Signature of Plaintiff \-nVJ9f! 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. •&ATCIFP(REV. 9/02) CSINIBOS/CINIB02 TEXAS DEPARTMENT OF CRIMINAL JUSTICE ©4/01/15 LH30/SRA6141 IN-FORMA-PAUPERIS DATA 13:48:40 TDCJ#: 01273988 SID#s 06630035 LOCATIONS JAMES LYNAUGH INDIGENT DTEs 11/07/14 NAME: ROBERTS,.DARRELL BEGINNING PERIOD: 10/01/14 PREVIOUS TDCJ NUMBERS: CURRENT BALs 0.70 TOT HOLD AMT: 50.00 3MTH TOT DEPs 0. 70 6MTH DEPs 30.70 6MTH flVG BAL: 0.34 6MTH AVG DEP: MONTH HIGHEST BALANCE TOTAL DEPOSITS MONTH HIGHEST BALANCE TOTAL DEPOSITS 03/15 0.70 0.00 IS/14 0.00 0.00 02/15 0.70 0.00 11/14 30.00 50. 00 01/15 0.70 0.70 10/14 0.00 0. 00 PROCESS DATE HOLD AMOUNT HOLD DESCRIPTION STATE OF TEXAS COUNTY OF Peaf* ON THIS THE J_ DAY OF &££, , ££, I 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 SIGs PF1-HELP PF3--END ENTER NEXT TDCJ NUMBER: OR SLBHMUMBER: C^^ t/iq -3^(3 &-/TAcS f/ £>739-?i SAWU6L G. » mi Motiry Public. State «' Texas « My Commissi"'! Expires 03 21 201* • * o e o « « « * , owd N-m1J»»' V wl,hf"'