Alfred Lee Stone v. Sgt. Allen Baskin ( 2014 )

13U14- oo3l£j -cjJ
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF TEXAS
T\\WL DIVISION FILED IN COURT OF APPEALS
Is restrict
Plaintiff's name and ID Number 2 9 2014
Tfi.tR
Place of Confinement CATHY S. LUSK, CLERK
CASE NO.
(Clerk will assign the number)
'a. 6.ASkiid APPLICATION TO PROCEED
IN FORMA PAUPERIS
Defendant's name and address
I, i\\\'VUl£\ ICJL-/ sJlLJJL-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 • No D^
c. Pensions, annuities or life insurance payments? Yes • No Q^
d. Gifts or inheritances? Yes • No Q^
e. Family or friends? Yes • No \2T
f. Any other sources? Yes • No Q^
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 checking or savings account, including any funds
in prison accounts? ^
Yes • No \J
If you answered YES to any of the questions above, state the total value of the items owned.
-&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, 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 A% day of tOLCL. ,20 l4.
G^iuA J)uJ A±Bu*j 5^LLS
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 LIBRARY AT YOUR PRISON UNIT.
-&ATCIFP (REV. 9/02)