Case Information
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IN THE UNITED STATES DISTRICT COURT
FOR mE [1] '. • . DISTRICT OF TEXAS DIVISION
Plaintiff's name and ID Number
Place of Confmement /-'1 :'\- D O.,i) 'E,U J'r
CASE NO._..,--__ -r_c.. __ - ___ _ (Clerk will assign the number) v. c·l-e~-kp Tit'~!A·-1 ~ s- Ccu..~\1"'[
· D ~s r-~~ 1s c.:r APPLICATION TO PROCEED \-q., 3 b % G -r, q <.:J ~W '3 P, ~- .l3o~ IN FORMA PAUPERIS "1 & {.17 "1 A--t-4. If 1.: liJ "1'-t::-AA-~
Defendant's name and address Q_ II : ''. t , -~-· . l'' " V• c . .1. tot- u-d"" u deClare, depose, and say I am the Plaintiff in the above entitled case. In support
I, l<.ttt-1""' VL of iny 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? e. Family or friends? . d. Gifts or inheritances? c. . Pensions, annuities or life insurance payments? b. Rent payments, interest or dividends? f. Any other sources? Yes Yes [0] Yes Yes 0 0 0 Yes 0 0 Yes [0] No No No NoW c::r No r.a--' 8"' No [3/.
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 checldJlg or savings account, including any funds·
·in prison accounts? Yes No E'r
If you answered YES to any of the questions above, state the 'total value of the items owned.
-t.ATCIFP (REV. 9/02) *12 3. Do you own real estate, stocks, bonds, note, automobiles, or other valuable property, excluding
ordinary household furnishings and clothing?
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).
Signed this the __ [0] _r _n_~_:f __ day of--~-- A:f_. _·u:._Vf_;, ' ___ _, 1:3"". :#/21/?f/ f/
~~??~..:;iT -Signature of Plaintiff ID Number
YOU MUST ATTACH A CURRENTSIX (6) MONTH HISTORY OF
YOUR INMATE TRUST ACCOUNT. YOU CAN ACQUIRE THE
APPROPRIATE INMATE ACCOUNT CERTIFICATE FROM THE
LAW LIBRARY AT YOUR PRISON UNIT •. uATCIFP (REV 9/02) *13 TEXAS DEPARTMENT OF CRIMINAL JUSTICE 03/10/15 C~INIB0~/CINIB02 DH31/SR00118 IN-FORMA-PAUPERIS DATA 09:02:50 TDCJ#: 01247914 SID#: 04344114 LOCATION: DALHART INDIGENT DTE: 02/23/15 NAME: ADRMS,CHARLES BEGINNING PERIOD: 08/01/14
PREVIOUS TDCJ NUMBERS: 01012355
CURRENT BAL: 0.35 TOT HOLD RMT: 0.00 3MTH TOT DEP: 0.00 6MTH DEP: 100.00 6MTH RUG BRL: 6.60 6MTH RUG DEP: 16.67 MONTH HIGHEST BALANCE TOTAL DEPOSITS MONTH HIGHEST BALANCE TOTAL DEPOSITS 01/15 1.70 0.00 10/14 102.24 100.00 12/14 1.70 0.00 09/14 2.24 0.00 11/14 1.99 0.00 08/14 2.24 0.00 PROCESS DATE HOLD AMOUNT HOLD DESCRIPTION
STATE OF TEXAS COUNTY OF HARTLEY_
ON THIS THE I DAY OF MAQ C:. H , T;, I CERTIFY THAT THIS DOCUMENT IS A TRUE, COMPLETE,RND UNALTERED COPY MADE BY ME OF INFORMATION CONTAINED IN THE
COMPUTER DATABASE REGARDING THE OFFENDER'S ACCOUNT. NP SIG:
PFl-HELP PF3-END ENTER NEXT TDCJ NUMBER: OR SID NUMBER:
/if:~·~·~\ ROBERT E. STOUT }*! MY COMMISSION EXPIRES ~\ "~<k· .. -~ August28 2017 .,,r.N&,, • ~£.~
03-!0-~0i.!:>
*14 TEXAS DEPARTMENT OF CRIMINAL JUSTICE RECORDS RELEASE
AUTHORIZATION I, the below named and numbered offender, hereby authorize the Texas Department of Criminal to release records pertaining to my trust . fund account, as request~d by IIJfllfl!.. dC0$7?l C'k&t. Ccx.;~z C/4'cv/tll91 (Identify Court, Attorney, or entity as 4'a 8o...V /2 .Jo8 c...;.L"J//ZJC. S/#~.AJ defined in Rule 3 9 2 !-Special Correspondence Rules) r&:• ,- /tw.s 7//v 0 ' 7!3 7// I, offender ~~ ~ ' - TDCJ# _/Z._L_V_7___:.9_'/_._Y __ being presently incarcerated at the _ _,().c:.._W.:...:'L.=:!:h'-"~!..!.!...V<...:::.T.__ __ _______ Unit/Facility of the ;/;l12. 72)1 Texas Department of Criminal Justice, in County, Texas declare under penalty of peJ.jury that the foregoing is true and correct 20 ;s-
Executed on this the ----=-/,-"''t)"--'--'llt-L--___ day of 12711/Zc/1 By .. Cb.zab _?~ Witness
(Offender Signature) (Approved-Witnessing Authority Signature) INSTRUCI'IONS:
1 The offe:nder completes above information, signs and dates the
Records Release Authorization in the presence of the approved
witnessing authority (Access to Courts Representative)
[2] The witnessing authority identifies the offender by ID card or
records ;md, upon verification, witnesses the offender's signature
by signing the Records Release Authorization, which the
witnessing authority will maintain
[3] The witnessing authority prints out a copy of the offender's
"TFBA" computer screen, certifies it, and retains a duplicate copy
for their records The offender is required to have an addressed, stamped envelope
prepared for mailing The witnessing authority then places a copy
of the c•::rtified "TFBA" printout in the addressed and stamped
envelope and the envelope is sealed and placed in the outgoing
ATC01- Authorization No. 1 (10/01)