Case Information
*1 A3
&imk ^k OfZ v Tr '<-- <s> .-'■■; —I "-O /Jo 367/Z<? 3/3^7 fh>t{U0<l fas Fen* m-fli r^j frb 73 7 * :ff c ^J y J / /■ . / /^aW debt < it* S Oenv) Mude /a/ /fly case nJ 'fl-4? /y - Cede 6~* t/hftw i a/a / fro OPa^ r ~ ■ _ r hfrve *2 he, '/s m h\ua y (rven a -[ <fa ft/Imy made
uJ&i
-HcA- -fu
uO*s
56 (sr\ <$ -k
,
Sirica
}*)
fu Crf MO ha fak phcej/ /
2.
PETITIONER'S INFORMATION
*3 Petitioner's printed name: State bar number, if applicable: Address: Telephone:, Fax:
INMATE'S DECLARATION
fVkrh i, , am the applicant / petitioner (circle one) and i>7 (/UhtitAf Jt/5n&? , declare under penalty of being presently incarcerated in A perjury that, according to my belief, the facts stated in the above application are true and correct.
Signed on
'3 Te b
20^.
Signature of Applicant / Petitioner (circle one)
17 Rev. 01/14/14 *4 TTT-V h. INMATE REQUEST FOR INFORMATION SID# MAIN JAIL: UNIT:
CIRCLE ONE (1) SECTION ONLY OR REQUEST WILL BE VOIDED
\W <
Information
Provided By: Section:
Inmate's Signature (Sign At Time Of Request)