1\J:lPf..~~ .AO 240 (Rev. 07/1 0) Application to Proceed in~ Court Without Prepaying Fees or Costs (Short Form) ~UG ~! 2~ ~ SEVENTH COURT OF APPEALS VIVIAN LONG. CLERK S ~\.\~u.I L.~[_\::- \'S..~-\\:f)fY\I_h_\._6 tJ\sL \U\..\\UibU~ ~l_\.5_ ~a~~ _t..\1 i\L\ t n\1,\h~ult...~M:.t !'"~~\\.~~" ~\Ri.Jll L....n.uQ.:\:_ t..~SI:'_ llu\\.\\bu ~ ld<~h~- ~ 1\fl~t.LLl\ll..t:., rn an ttrsr . v. ) Civil Action No. h'?t*t~~\,t.\t:± ~\_. ) )
APPLICATIO N TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Short Form)
I am a plaiAfrfe~~\r~~'fin this case and declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief requested. ·
In support of this application, I answer the following questions under penalty ofpetjury:
I. If incarcerated. I am being held at: \h~ a1 t....\\ \i..i \£-~J.. \_l.J_\.±._ If employed there, or have an account in the institution, I have attached to this document a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any institutional account in my name. I am also submitting a similar statement from any other institution where I was incarcerated during the last six months.
2.1fnot incarcerated. If I am employed, my employer's name and address are: ·~\l-
My gross pay or wages are: $ ___=fi .........-___ , and my take-home pay or wages are: $ --~......._~_ _ _ per (specify pay period) _ _ _ _-b.: __,._____
3. Other Income. In the past 12 months, I have received income from the following sources (check all that apply):
(a) Business, profession, or other self-employment 0 Yes (b) Rent payments, interest, or dividends 0 Yes (c) Pension, annuity, or life insurance payments 0 Yes (d) Disability, or worker's compensation payments 0 Yes (e) Gifts, or inheritances (f) Any other sources 0 xes qv'Yes ONo
Ifyou answered "Yes" to any question above, describe below or on separate p:rt each source ofmoney and state the amount that you received and what you expect to receive in the future. \:\"'L.~ t...\\.\..~ ~\:..\\lll.L~\ ~\QQ. DID tlu :h\a1\ \~ \ lilto~L~.._tt-5.\t\c.c.o \~\co\\1\. SL.S-'t..\'Lt', ~tiraQ ~1,-\:...'t...S ki \oo-co t\ \ 1.\~tl\lt .5~t', ~. Q\L~~ ~" L'f...thf..!. \9-fi:~.~ \~\~\1k~\"\, ~ h~L~~~ ~Y\..\';..'li,!..~ \oo.c,c q\ 1\~n.\~-. ~uVoLL ~~-. ~~'t'~<\\.~ "l\~\ \ ~~\1.\l lh.h:nt..L ~l"'=...~ SL!:..t..L\' j\ l.ob ..Oc L.\ll\.1~\t.t·\ ~u\0~ ~1\:\:..~ :S~t' \\t~\ b..\l\S. . lloo... ~~ . AO 240 (Rev. 07/10) Application to Proceed in ~Court Without Prepaying Fees or Costs (Short Fonn)
4. Amount ofmoney that I have in cash or in a checking or savings account: $ _ _ __..D,_______
5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other fmancial instrument or thing of value that I own, including any item of value held in someone else's name (describe the property and its approximate value): -o-
6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide the amount of the monthly expense):
7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship with each person, and how much I contribute to their support: J -o
8. Any debts or fmancial obligations (describe the amounts owed and to whom they are payable): "L ~~'b.._ \:hC..:S.. ~\:.l;...\IL~~ti \1.~\...~ \\b~u..t AUi~.cc ~~'( Ltltf..\._<\At..\l\::.. ~u99DlS,
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Declaration: I declare under penalty of perjury that the above information is true and understand that a false statement may result in a dismissal of my claims.
Date:
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1\J:lPf..~~ .AO 240 (Rev. 07/1 0) Application to Proceed in~ Court Without Prepaying Fees or Costs (Short Form) ~UG ~! 2~ ~ SEVENTH COURT OF APPEALS VIVIAN LONG. CLERK S ~\.\~u.I L.~[_\::- \'S..~-\\:f)fY\I_h_\._6 tJ\sL \U\..\\UibU~ ~l_\.5_ ~a~~ _t..\1 i\L\ t n\1,\h~ult...~M:.t !'"~~\\.~~" ~\Ri.Jll L....n.uQ.:\:_ t..~SI:'_ llu\\.\\bu ~ ld<~h~- ~ 1\fl~t.LLl\ll..t:., rn an ttrsr . v. ) Civil Action No. h'?t*t~~\,t.\t:± ~\_. ) )
APPLICATIO N TO PROCEED IN DISTRICT COURT WITHOUT PREPAYING FEES OR COSTS (Short Form)
I am a plaiAfrfe~~\r~~'fin this case and declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief requested. ·
In support of this application, I answer the following questions under penalty ofpetjury:
I. If incarcerated. I am being held at: \h~ a1 t....\\ \i..i \£-~J.. \_l.J_\.±._ If employed there, or have an account in the institution, I have attached to this document a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months for any institutional account in my name. I am also submitting a similar statement from any other institution where I was incarcerated during the last six months.
2.1fnot incarcerated. If I am employed, my employer's name and address are: ·~\l-
My gross pay or wages are: $ ___=fi .........-___ , and my take-home pay or wages are: $ --~......._~_ _ _ per (specify pay period) _ _ _ _-b.: __,._____
3. Other Income. In the past 12 months, I have received income from the following sources (check all that apply):
(a) Business, profession, or other self-employment 0 Yes (b) Rent payments, interest, or dividends 0 Yes (c) Pension, annuity, or life insurance payments 0 Yes (d) Disability, or worker's compensation payments 0 Yes (e) Gifts, or inheritances (f) Any other sources 0 xes qv'Yes ONo
Ifyou answered "Yes" to any question above, describe below or on separate p:rt each source ofmoney and state the amount that you received and what you expect to receive in the future. \:\"'L.~ t...\\.\..~ ~\:..\\lll.L~\ ~\QQ. DID tlu :h\a1\ \~ \ lilto~L~.._tt-5.\t\c.c.o \~\co\\1\. SL.S-'t..\'Lt', ~tiraQ ~1,-\:...'t...S ki \oo-co t\ \ 1.\~tl\lt .5~t', ~. Q\L~~ ~" L'f...thf..!. \9-fi:~.~ \~\~\1k~\"\, ~ h~L~~~ ~Y\..\';..'li,!..~ \oo.c,c q\ 1\~n.\~-. ~uVoLL ~~-. ~~'t'~<\\.~ "l\~\ \ ~~\1.\l lh.h:nt..L ~l"'=...~ SL!:..t..L\' j\ l.ob ..Oc L.\ll\.1~\t.t·\ ~u\0~ ~1\:\:..~ :S~t' \\t~\ b..\l\S. . lloo... ~~ . AO 240 (Rev. 07/10) Application to Proceed in ~Court Without Prepaying Fees or Costs (Short Fonn)
4. Amount ofmoney that I have in cash or in a checking or savings account: $ _ _ __..D,_______
5. Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other fmancial instrument or thing of value that I own, including any item of value held in someone else's name (describe the property and its approximate value): -o-
6. Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe and provide the amount of the monthly expense):
7. Names (or, if under 18, initials only) of all persons who are dependent on me for support, my relationship with each person, and how much I contribute to their support: J -o
8. Any debts or fmancial obligations (describe the amounts owed and to whom they are payable): "L ~~'b.._ \:hC..:S.. ~\:.l;...\IL~~ti \1.~\...~ \\b~u..t AUi~.cc ~~'( Ltltf..\._<\At..\l\::.. ~u99DlS,
~ .{_"'._)..\,_ \\.\\.\\ \:L l ~~ ""~"'--)
Declaration: I declare under penalty of perjury that the above information is true and understand that a false statement may result in a dismissal of my claims.
Date:
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~ ~IIG ~l2~ ~ SEVENTH COURI OF APPEALS VIVIAN LONG, CLERK TEXAS DEPARTME.f.JT OF CRIMINAL JUSTICE- INSTITUTIONAL DIVISION
INMATE REOUESTTO OFFICIAL •... ,, ... - >
REASON FOR REQUEST: (Please check one)
PLEASE ABIDE BY THE FOLLOWING CHANNELS OF COMMUNICATION. THIS WILL SAVE TIME, GET YOUR REQUEST TO THE PROPER PERSON, AND GET AN ANSWER TO YOU MORE QUICKLY.
1. Unit Assignment, Transfer (Chaii-man of Classification, 5. Visiting List (Asst. Director of classification, Administration Administration Building) ./!· Building)
2. Restoration of Lost overtime (Unit Warden-if approved, it 6. Parole requirements and related information (Unit Parole will be forwarded to the State Disciplinary Committee) Counselor) . .
3. Request for Promotio~ 'in c1ass or to TrusWan ~~ 7. - ~&l,~rison Record (Request to(: copy of record, infor- (Unit Warden- if approved,· will be ~orwarded to th? ljeclt;J V <•~ ~~Jgt/on parole eligibility, discharJe date, detainers-Unit
w. of Classification) ··. "·,.. ~.'·;,.;..~· Ao' ,,.i': · --~. J_,_.·. ·· ' -· Administration) .
C/emency~Pardon, parole, earlyoul~mandato')'su:ltiij\. -:. ~.f.~ -~ 'l-. .· 4. · fi/tp_;:r~pre$entative of an outside ~ '-:.~: -~-jl ' (Board of Pardons and Paroles, 8610 Shoal Cree Dt sffJn, 11.dm/nistration Building) Austin, Texas 78757)
TO: ~\\~.. \\); Y \\\ 1\\\cl 'i; 1 . DATE: ~~\aD.\~ (Name and title of official)
ADDRESS:~.~.,_.,.._..l--------------------~----------~----
SUBJECT: State briefly the problem on which you des(re assistance.
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