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case no. flV/6-Oo730-6l/ (Clerk will assign the number)

APPLICATION TO PROCEED IN FORMA PAUPERIS ^0/iKy< L/ll/yt/^ \Jvu*Ia Defendant's name and address*'/

I, vl/lM/n MutrtQ (.yrfovi 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 or dividends? Yes n No H" c. Pensions, annuities or life insurance payments? Yes H No Bf d. Gifts or inheritances? Yes [J No U e. Family or friends? Yes « No • f. Any other sources? Yes • No H' 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.

iLf^iVwA IhJk l.e,<-r 1% \>„>nUf 6{>fx SQ^ 4rTon, fr.. mom f6/A P Do you own cash, or do you have money in a checking or savings account, including any funds in prison accounts? ^ Yes T | No • If you answered YES to any of the questions above, state the 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 a^ 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 0<C, day of Uov-en> \>^f ,20 /U.

KV^k?^ j&^ i°miros Signature of Plaintiff 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 LD3RARY AT YOUR PRISON UNIT.

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