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/RECEIVEDN JAN 0 4 2017 "vTHiRD COURT OF APPEALS ) \_JFTOYAKYtE_/ LSiNiB0£/ClNIB0E TEXAS DEPARTMENT OF CRIMINAL JUSTICE 12/27/16 ".L 0 7 £ / 3 M 0 ft 0 © 4 I N - F Li R M A -!:::' A U P E' RIS D A T A 0 9 :; 5 © s4 0 'DC J# ; 01 163 :l 01 31 D# :; 05925934 LOCATI ON s ELL IG INDI GENT DTE : 'AME:; BRUGMANN, MICHAEL TERRY BEGINNING PERIOD:: 06/3:1/16 ;• REV IOUS TDC J MUMBERG :: CURRENT BAL:; 146,. £1 TOT HOLD ANT; 8,. 00 3MTH TOT DEP;: 150. C NTT'H DEP;; 350.013 6 NTH AUG BAL.: '54-84 6 NTH PUG DEP:: 53.. 3 NGMTH HIGHEST BALANCE TOTPL DEPOSITS MONTH HIGHEST BALANCE TOTAL DEPOSITS i i / 1S 10S. 3 £ 5 0, 0 0 0 8/16 3.0 4 . 1 1 :!. 0 0, 0 0 •0/16 77.95 50.00 07/16 50.. 13 50„ 00 ^9/16 78.. 73 50„ 00 06/16 63.37 50,00 PROCESS DATE HOLD ftMOUNT HOLD DESCRIPTION

TATE OF TEXAS COUNTY OF bJc\(<j*f N THIS THE £7^4)flY OF „C^W CERT Ir ••iAT th: TCUMENT COMPLETE, AND UNALTERED COPY MODE BY ME : N F 0 R M A T10 N C 0 N T AIN E T lyi Tl-JP' ;OMPUTER DATABASE REGARDING THE OFT'EME ACCOUNT,, HP SIC:; 'Fl-HELP PF3--END ENTER NEXT TDC J' NUMBE flR R'I'D NH'vip.P-"

eo»o»oooooooooooo»00»oeao M. SCHANFISH ?

W N°tary Public. State of Texas ° My Commission Expires e 10-27-2017 0 oooeeao«oo9o«oooooeoooooo Notary Without Bond

RECEIVED^ JHIRDC0UR70FAPPEALS J IN THE UNITED STATES DISTRICT COURT FOR THE W DISTRICT OF TEXAS DIVISION 3f C<nu»t~ ^4 fyp*a(; /9ujh0/-m /Iruj/n*/)/) /n/rA^s / Tlcrr* aintiff's Plainti name and ID Number e/l« / foil M^ottbT*. -7-73W Place of Confinefhent

CASE NO. (Clerk will assign the number) V. APPLICATION TO PROCEED IN FORMA PAUPERIS

Defendant's name and address

ViWchatl 7iftu &u&*t6»^ , declare, depose, and say I am the Plaintiff in the above entitled case. In support ofmy motion to proceed without being required toprepay fees, costs, orgive 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 [ET b. Rent payments, interest or dividends? Yes • No \Pf c. Pensions, annuities or life insurance payments? Yes • No \Df d. Gifts or inheritances? Yes • No 0^ e. Family or friends? Yes |g) No • f. Any other sources? Yes D No df 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.

rfb-fhlr S/'/utrS'o,0* s/o//AfS a. /y>omk6u>tf/eo,*0c'a//Arj £r CAstrU^r wASrfrtJy 2. Do you own cash, ordo you have money in a checking orsavings account, including any funaS k'vcD \ in prison accounts? 1 Mqa ?nI7 Yes [2 No D I U,/ \TH'R?C0l/RrOFAPPEAL If you answered YES to any of the questions above, state the total value of the items ownedi«i£SsY (!KV£__,

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

Yes • No 0^ If you answered YES, describethe 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 <2? K dav of Z>ect*6tr- , 20 /£ .

Signature of Plaifitiff ^ 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) ~K-

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