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IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF TEXAS
/ld6t hJ DIVISION

1\.IFK ed }.oL oroi'JL 5Gl1~b6
Plaintiff's name and ID Number

Place of Confinement

CASE NO. _ _ _ _ _ _ _ _ __
(Clerk will assign the number)
v.
TUc f-\ (=n! ~u~t;\ d\: Af>pe.Alo APPLICATION TO PROCEED

~i l!k M~uiS
IN FORMA PAUPERIS

Defendant's name and address

1,41. F111U\ l.t.L 6\0ttJ, ~clare, 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.

l- 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@
b. Rent payments; interest or dividends? Yes 0 No~
c. Pensions, annuities or life insurance payments? Yes 0 No~
d. Gifts or inheritances? Yes 0 No~
e. Family or friends? Yes 0 No [a/
f. Any other sources? · Yes 0 Nog/

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.

2. Do you own cash, or do you have money in a checking or savings account, including any funds
in prison accounts?
Yes 0 No rz('
If you answered YES to any of the questions above, state the total value of the items owned.

·AATCIFP (REV. 9/02)
 3. Do you own real estate, stocks, bonds, note, automobiles, or other valuable property, excluding
ordinary household furnishings and clothing?

Yes 0 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,___ _d.ay of
__,;2=· ,j U \ ~ , 20 ~6.

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 LffiRARY AT YOUR PRISON UNIT.

2 ~ATCIFP (REV. 9/02)
 "i
CSINIB08/CINIBel2 TEXAS DEPARTIYIENT OF CRIMINAL JUSTICE 07/23/15
E223/DPH2185 IN-FORMA-PAUPERIS DATA 11 : 1ZI3: L•6
TDCJ#~ 00599665 SID#: 03028672.LOCATION: ESTELLE INDIGENT DTE: 04/18/13
NAME: STONE,ALFRED LEE BEGINNING PERIOD:
PREVIOUS TDCJ NUMBERS: 00562542
CURRENT BAL: 20.20 TOT HOLD AMT: 100.00 3MTH TOT DEP:
6MTH DEP: 6MTH AVG BAL: 6MTH AVG DEP:
MONTH HIGHEST BALANCE TOTAL DEPOSITS MONTH HIGHEST BAL~NCE TOTAL DEPOSITS

PROCESS DATF.::: HOLD AMOUNT HOLD DESCRIPTION

NO BANKING ACTIVITY
WITHIN THE PAST 6
MONTH PERIOD.

STATE OF TEXAS COUNTY OF~
ON THIS THE DAY OF :S:
J(!; /0__, I CERTIFY THAT THIS DOCUMENT IS A TRUE?
COMPLETE,AND UNALTERED COP MADE BY ME OF INFORMATION CONTAINED IN THE
COMPUTER DATABASE REGARDING THE OFFENDER'S ACCOUNT. NP SIG:
PF1-HELP PF3-END ENTER NEXT TDCJ NUMBER~ OR SID NUMBER:

,·············~·········
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