(..`._~_;)' n ," IN THE UNITED STATES DISTRICT COURT § ~ _. § FoR THE 92 DISTRICT oFTEXAs _ , j ' 1_ D_IvlsloN

CO RECEll/ED IN \k.a\m\k \,1 11 (@1”3?)°3'5 ’ , URT °FCR"""NALAPPEALS 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 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 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 ‘ 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)