UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA
ANTHONY LEWIS, PLAINTIFF,
V. CASE NO,
UNTIED STATES OF AMERICA, et al., DEFENDANTS,
PLAINTIFF'S REQUEST TO PROCEED INEORMA PAUPERIS Now comes the plaintiff, Anthony I.ewis, pro-se,
in the above styled cause, and request this honorable court to
grant him leave to proceed in forma pauperis with the litigation
of the present civil action, without prepayment of cost or fee,
given the fact that he is indigent and cannot prepay the cost or
fee upon the filing of the civil complaint. The plaintiff has
provided the court a copy of his institutional account in support
of his indigency.
Wherefore, the plaintiff request this honorable court
to grant his request for leave to proceed in forma pauperis
with the present civil action, without prepayment of cost or
fee.
Respect^lly Submitted,
'^rithony Lewis, Pro~se Reg. NoV 17215-018 FCC Coleman-Medium P.O. Box 1032 Coleman, Florida 33521-1032
rix kim o Mail Room
KhCRn r.fi" Mail Room
A^'jida D. Caesar. Clerk of Co^ n S/Ti^lricl rniirl. Dislr"-' "fr.nlumO^- u 'J. t Icik of I S Diainu tourl, Dislrici ofCohimlMi! I ^AO240 (Rev. 10/03) I
United States District Court District of COLUMBIA
Anthony Lewis, APPLICATION TO PROCEED Plaintiff WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT V.
United States of America, et al. , CASE NUMBER; Defendant
I, Anthony Lewis declare that I am the (check appropriate box) •petitioner/plaintiffmovant/respondent • other in the above-entitled proceeding; that insupport of myrequest toproceed without prepayment of fees orcosts under 28 USC §1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in the complaint/petition/motion. In support of this application, I answer the following questions underpenalty of peijury: 1. Are you currently incarcerated? )lXKYes • No (If"No,"go toPart2) If"Yes," state the place ofyour incarceration FCC Coleman-Medium Are you employed at the institution? Ml. Do you receive any payment from the institution? No Attach a ledger sheet from the institution(s) of your incarceration showing at least the pastsix months' transactions.
Are you currently employed? • Yes XE^o a If the answer is "Yes," state the amount ofyour take-home salary or wages and pay period and give the name and address of your employer. (List both gross and net salary.) N/A
b. Ifthe answer is "No," state the date ofyour last employment, the amount ofyour take-home salary or wages and pay period and the name and address of your last employer. August 1993
In the past 12 twelve months have you received any money from any ofthe following sources? a. Business, profession or other self-employment • Yes NXKNo b. Rent payments, interest or dividends • Yes WNo Rcom c. Pensions, annuities or life insurance payments • Yes )®Mo d. Disability or workers compensation payments • Yes ^0^0 e. Gifts or inheritances • Yes f. Any other sources • Yes Wno L lirk ol t.uuii ? _ S District touft, District orColumhia { If the answer to any ofthe above is "Yes," describe, on the following page, each source ofmoney and state the amount received and what you expect you will continue to receive. N/A AO 240 (Rev 07/10) Application to Proceed m District Court Without Prepaying Feesor Costs(Short Form)
4 Amount ofmoney that I have mcash ormachecking orsavings account $ N/A 5 Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or thing of value that I own, including any item of value held in someone else's name (describe the property anditsapproximate vqIi^c) I have been incarcerated for more than twenty (20) years. I am Indigent.
6 Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe andprovide the amomt ofthe monthly expense)
N/A
I do not have any of the above due to incarceration for more than twenty (20) years.
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
N/A I do not have any of the above due to incarceration for more than twenty (20) years.
8 Any debts or financial obligations (describe the amounts owedand to whom they are payable)
N/A I do not have any of the above due to incarceraton for more than twenty (20) years.
Declaration I declare under penalty ofperjuiy that the above information is true and understand that a false statement may result m a dismissal of my claims
Date. " / v / Applicant s signature
/ Printed name InmateStatementCombined Page 1 of2
Inmate Statement Inmate Reg # 17215018 Curient Institution Colenitin FCC
Inmate Name LEWIS ANTHONY Housing I nit COM-B-C
Report Date 1)8/14/2014 I iMng Qualtcl^ B05-0I6U
Report I ime 2 57 17 PM Transaction Encumbrance Aloha Reference# Payment# Receint# Transaction Tvne Amount Amount Endinp Balance Code Date/Time 59 Sales ($7 25) $22 49 CCA 8/14/2014 1 40 54 PM COA 8/14/2014 TFN0814 Phone Withdrawal ($3 00) $29 74 12 06 15 PM COA 8/11/2014 TFN0811 Phone Withdrawal (S3 00) $32 74 4 47 22 PM COA 8/9/2014 TL0809 TRUL Withdrawal (S5 00) $35 74 9 05 33 AM COA 8/7/2014 TL0807 TRUL Withdrawal ($2 00) $40 74 2 16 36 PM COA 8/6/2014 64 Sales ($92 90) $42 74 6 21 08 PM COA 8/5/2014 TFN0805 Phone Withdrawal ($7 00) $135 64 6 50 42 PM COA 8/3/2014 33314215 Western Union $100 00 $142 64 7 06 03 PM COA 8/2/2014 TFN0802 Phone Withdrawal ($3 00) $42 64 11 46 11 AM COA 7/31/2014 TFN0731 Phone Withdrawal ($5 00) $45 64 5 30 18 PM COA 7/31/2014 TL0731 TRUL Withdrawal ($2 00) $50 64 3 11 32 PM COA 7/31/2014 TFN0731 Phone Withdrawal ($3 00) $52 64 8 45 03 AM COA 7/30/2014 6 Sales ($10 85) $55 64 12 50 57 PM COA 7/30/2014 TL0730 TRUL Withdrawal ($2 00) $66 49 9 58 25 AM COA 7/29/2014 TL0729 TRUL Withdrawal ($2 00) $68 49 1 26 25 PM COA 7/29/2014 TFN0729 Phone Withdrawal ($5 00) $7049 11 51 51 AM COA 7/28/2014 TFN0728 Phone Withdrawal ($3 00) $75 49 5 23 45 PM COA 7/28/2014 TL0728 TRUL Withdrawal ($2 00) $78 49 10 00 13 AM COA 7/26/2014 TFN0726 Phone Withdrawal ($3 00) $80 49 3 34 07 PM COA 7/26/2014 TL0726 TRUL Withdrawal ($2 00) $83 49 9 11 09 AM COA 7/25/2014 TFN0725 Phone Withdrawal ($3 00) $85 49 5 03 23 PM COA 7/25/2014 TFN0725 Phone Withdrawal ($2 00) $88 49 2 34 49 PM COA 7/25/2014 TL0725 TRUL Withdrawal ($2 00) $9049 9 37 04 AM COA 7/24/2014 TFN0724 Phone Withdrawal ($3 00) $92 49 8 31 20 PM COA 7/23/2014 TFN0723 Phone Withdrawal ($2 00) $95 49 5 06 01 PM COA 7/23/2014 11 Sales ($98 05) $97 49 12 48 17 PM COA 7/23/2014 33314204 Westem Union $100 00 $195 54 12 06 26 PM COA 7/22/2014 TFN0722 Phone Withdrawal ($6 00) $95 54 9 20 51 PM COA 7/22/2014 33314203 Westem Union $100 00 $101 54 6 07 25 PM COA 7/22/2014 TFN0722 Phone Withdrawal ($1 00) $1 54 12 22 44 PM COA 7/21/2014 TFN0721 Phone Withdrawal ($1 00) $2 54 10 43 20 AM COA 7/21/2014 TL0721 TRUL Withdrawal ($2 00) $3 54 9 52 09 AM
https //lO 33 124 106/truweb/InmateStatementCombined aspx 8/14/2014 ImnateStatementCombined Page 2 of2
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UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA
ANTHONY LEWIS, PLAINTIFF,
V. CASE NO,
UNTIED STATES OF AMERICA, et al., DEFENDANTS,
PLAINTIFF'S REQUEST TO PROCEED INEORMA PAUPERIS Now comes the plaintiff, Anthony I.ewis, pro-se,
in the above styled cause, and request this honorable court to
grant him leave to proceed in forma pauperis with the litigation
of the present civil action, without prepayment of cost or fee,
given the fact that he is indigent and cannot prepay the cost or
fee upon the filing of the civil complaint. The plaintiff has
provided the court a copy of his institutional account in support
of his indigency.
Wherefore, the plaintiff request this honorable court
to grant his request for leave to proceed in forma pauperis
with the present civil action, without prepayment of cost or
fee.
Respect^lly Submitted,
'^rithony Lewis, Pro~se Reg. NoV 17215-018 FCC Coleman-Medium P.O. Box 1032 Coleman, Florida 33521-1032
rix kim o Mail Room
KhCRn r.fi" Mail Room
A^'jida D. Caesar. Clerk of Co^ n S/Ti^lricl rniirl. Dislr"-' "fr.nlumO^- u 'J. t Icik of I S Diainu tourl, Dislrici ofCohimlMi! I ^AO240 (Rev. 10/03) I
United States District Court District of COLUMBIA
Anthony Lewis, APPLICATION TO PROCEED Plaintiff WITHOUT PREPAYMENT OF FEES AND AFFIDAVIT V.
United States of America, et al. , CASE NUMBER; Defendant
I, Anthony Lewis declare that I am the (check appropriate box) •petitioner/plaintiffmovant/respondent • other in the above-entitled proceeding; that insupport of myrequest toproceed without prepayment of fees orcosts under 28 USC §1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in the complaint/petition/motion. In support of this application, I answer the following questions underpenalty of peijury: 1. Are you currently incarcerated? )lXKYes • No (If"No,"go toPart2) If"Yes," state the place ofyour incarceration FCC Coleman-Medium Are you employed at the institution? Ml. Do you receive any payment from the institution? No Attach a ledger sheet from the institution(s) of your incarceration showing at least the pastsix months' transactions.
Are you currently employed? • Yes XE^o a If the answer is "Yes," state the amount ofyour take-home salary or wages and pay period and give the name and address of your employer. (List both gross and net salary.) N/A
b. Ifthe answer is "No," state the date ofyour last employment, the amount ofyour take-home salary or wages and pay period and the name and address of your last employer. August 1993
In the past 12 twelve months have you received any money from any ofthe following sources? a. Business, profession or other self-employment • Yes NXKNo b. Rent payments, interest or dividends • Yes WNo Rcom c. Pensions, annuities or life insurance payments • Yes )®Mo d. Disability or workers compensation payments • Yes ^0^0 e. Gifts or inheritances • Yes f. Any other sources • Yes Wno L lirk ol t.uuii ? _ S District touft, District orColumhia { If the answer to any ofthe above is "Yes," describe, on the following page, each source ofmoney and state the amount received and what you expect you will continue to receive. N/A AO 240 (Rev 07/10) Application to Proceed m District Court Without Prepaying Feesor Costs(Short Form)
4 Amount ofmoney that I have mcash ormachecking orsavings account $ N/A 5 Any automobile, real estate, stock, bond, security, trust, jewelry, art work, or other financial instrument or thing of value that I own, including any item of value held in someone else's name (describe the property anditsapproximate vqIi^c) I have been incarcerated for more than twenty (20) years. I am Indigent.
6 Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe andprovide the amomt ofthe monthly expense)
N/A
I do not have any of the above due to incarceration for more than twenty (20) years.
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
N/A I do not have any of the above due to incarceration for more than twenty (20) years.
8 Any debts or financial obligations (describe the amounts owedand to whom they are payable)
N/A I do not have any of the above due to incarceraton for more than twenty (20) years.
Declaration I declare under penalty ofperjuiy that the above information is true and understand that a false statement may result m a dismissal of my claims
Date. " / v / Applicant s signature
/ Printed name InmateStatementCombined Page 1 of2
Inmate Statement Inmate Reg # 17215018 Curient Institution Colenitin FCC
Inmate Name LEWIS ANTHONY Housing I nit COM-B-C
Report Date 1)8/14/2014 I iMng Qualtcl^ B05-0I6U
Report I ime 2 57 17 PM Transaction Encumbrance Aloha Reference# Payment# Receint# Transaction Tvne Amount Amount Endinp Balance Code Date/Time 59 Sales ($7 25) $22 49 CCA 8/14/2014 1 40 54 PM COA 8/14/2014 TFN0814 Phone Withdrawal ($3 00) $29 74 12 06 15 PM COA 8/11/2014 TFN0811 Phone Withdrawal (S3 00) $32 74 4 47 22 PM COA 8/9/2014 TL0809 TRUL Withdrawal (S5 00) $35 74 9 05 33 AM COA 8/7/2014 TL0807 TRUL Withdrawal ($2 00) $40 74 2 16 36 PM COA 8/6/2014 64 Sales ($92 90) $42 74 6 21 08 PM COA 8/5/2014 TFN0805 Phone Withdrawal ($7 00) $135 64 6 50 42 PM COA 8/3/2014 33314215 Western Union $100 00 $142 64 7 06 03 PM COA 8/2/2014 TFN0802 Phone Withdrawal ($3 00) $42 64 11 46 11 AM COA 7/31/2014 TFN0731 Phone Withdrawal ($5 00) $45 64 5 30 18 PM COA 7/31/2014 TL0731 TRUL Withdrawal ($2 00) $50 64 3 11 32 PM COA 7/31/2014 TFN0731 Phone Withdrawal ($3 00) $52 64 8 45 03 AM COA 7/30/2014 6 Sales ($10 85) $55 64 12 50 57 PM COA 7/30/2014 TL0730 TRUL Withdrawal ($2 00) $66 49 9 58 25 AM COA 7/29/2014 TL0729 TRUL Withdrawal ($2 00) $68 49 1 26 25 PM COA 7/29/2014 TFN0729 Phone Withdrawal ($5 00) $7049 11 51 51 AM COA 7/28/2014 TFN0728 Phone Withdrawal ($3 00) $75 49 5 23 45 PM COA 7/28/2014 TL0728 TRUL Withdrawal ($2 00) $78 49 10 00 13 AM COA 7/26/2014 TFN0726 Phone Withdrawal ($3 00) $80 49 3 34 07 PM COA 7/26/2014 TL0726 TRUL Withdrawal ($2 00) $83 49 9 11 09 AM COA 7/25/2014 TFN0725 Phone Withdrawal ($3 00) $85 49 5 03 23 PM COA 7/25/2014 TFN0725 Phone Withdrawal ($2 00) $88 49 2 34 49 PM COA 7/25/2014 TL0725 TRUL Withdrawal ($2 00) $9049 9 37 04 AM COA 7/24/2014 TFN0724 Phone Withdrawal ($3 00) $92 49 8 31 20 PM COA 7/23/2014 TFN0723 Phone Withdrawal ($2 00) $95 49 5 06 01 PM COA 7/23/2014 11 Sales ($98 05) $97 49 12 48 17 PM COA 7/23/2014 33314204 Westem Union $100 00 $195 54 12 06 26 PM COA 7/22/2014 TFN0722 Phone Withdrawal ($6 00) $95 54 9 20 51 PM COA 7/22/2014 33314203 Westem Union $100 00 $101 54 6 07 25 PM COA 7/22/2014 TFN0722 Phone Withdrawal ($1 00) $1 54 12 22 44 PM COA 7/21/2014 TFN0721 Phone Withdrawal ($1 00) $2 54 10 43 20 AM COA 7/21/2014 TL0721 TRUL Withdrawal ($2 00) $3 54 9 52 09 AM
https //lO 33 124 106/truweb/InmateStatementCombined aspx 8/14/2014 ImnateStatementCombined Page 2 of2
COA 7/19/2014 TFN0719 Phone Withdrawal ($2 00) $5 54 11 33 08 AM COA 7/17/2014 40 Sales ($54 75) $7 54 1 30 21 PM COA 7/17/2014 TFN07I7 Phone Withdrawal ($3 00) $62 29 12 30 39 PM COA 7/16/2014 TFN0716 Phone Withdrawal ($2 00) $65 29 5 29 00 PM COA 7/16/2014 TFN0716 Phone Withdrawal ($3 00) $67 29 3 31 42 PM COA 7/15/2014 TL0715 TRUL Withdrawal ($2 00) $70 29 6 1641 AM COA 7/14/2014 TFN07I4 Phone Withdrawal ($3 00) $72 29 8 43 29 PM COA 7/14/2014 TFN0714 Phone Withdrawal ($5 00) $75 29 3 35 22 PM COA 7/14/2014 33314195 Western Union $80 00 $80 29 1 08 17 PM COA 7/12/2014 TFN0712 Phone Withdrawal ($1 00) $0 29 12 23 26 PM COA 7/11/2014 TFN0711 Phone Withdrawal ($1 00) $I 29 3 14 02 PM COA 7/10/2014 TFN0710 Phone Withdrawal (SI 00) $2 29 8 02 47 PM COA 7/10/2014 TFN0710 Phone Withdrawal ($I 00) $3 29 10 38 38 AM COA 7/9/2014 TFN0709 Phone Withdrawal ($1 00) $4 29 3 13 45 PM COA 7/9/2014 31 Sales (S43 40) $5 29 12 03 51 PM COA 7/7/2014 TFN0707 Phone Withdrawal ($3 00) $48 69 12 35 47 PM COA 7/7/2014 33314188 Western Union $50 00 $5169 11 08 03 AM COA 7/6/2014 TFN0706 Phone Withdrawal ($1 00) $169 8 50 16 AM 1 234 5i6 789
Total Transactions 411
Totals ($38 25) SO 00
Current Balances
Available Pre-Release Debt SPO Other Outstanding Administrative Account
Aloha Code Balance Balance Encumbrance Encumbrance Encumbrance Instruments Holds Balance
COA $22 49 $0 00 $0 00 $0 00 $0 00 $0 00 $0 00 $22 49
Totals $22 49 $0 00 $0 00 $0 00 $0 00 $0 00 $0 00 $22 49
Other Balances
National 6 NatioanI 6 Local Max Commissarv Commissarv
National 6 Months Months \ \ p Balance - Prev 30 Averape Balance Restriction Start Restriction End
Months Deoosits Withdrawals Dailv Balmce Davs - Prev 30 Davs Date Date
$1 925 00 $1,993 40 $53 85 $195 54 $57 67 N/A N/A
https //lO 33 124 106/truweb/IiiinateStatementCombined aspx 8/14/2014 UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA
CONSENT TO COLLECTION OF FEES FROM TRUST ACCOUNT
Re Anthony Lewis y United States of America,
Civil Action No
I. Anthony Lewis # 17215-018 ^ the appropnate prison official to withhold from my pnson account and to pay the U S Distnct Court an initial fee of20 percent of the greater of
(a) the average monthlydeposits to my account for the six-month period immediately preceding the filing of my complaint, or
(b) the average monthly balance m myaccount for the six-month penod immediately precedmg the filing of my complaint
I further consent for the appropnate pnson officials to collect from my account on a continuing basis each month, an amount equal to 20 percent of each month's income Each time the amount in the account reaches $10, theTrust Officer shall forward the intenm payment to the Clerk's Office, U S Distnct Court, until such time as the $350 00 filing fee is paid in full
If appropnate, I will execute the institution consent form where I am housed, which will permit the staffto withdraw the amount ordered by this court as payment for the filing fee each month until the $350 00 filmg fee is paid in full
By executing this document, I also authonze collection, on a continuing basis, anycosts imposed by the District Court
of Plaintiff
n \forms\Trust Account Form