McKinney v. Keeler et al

Western District of Texas, txwd-6:2018-cv-00060

MOTION to Proceed in forma pauperis by Unique McKinney.

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1 A0240 ev. 06/09) pplicañm to Proceed i Dis1ct Court Without Prpaying Fees or Costs (Short Form) F I LE C) UNITED STATES DIs TPJCT COURT forthe Western District of Texas U.S. OIST8U COURT. l/1')i9LL1 Thki4'-iruj /11u72 eVUTY TEXAS CLERK Paint Civil Action No. O Defendant) kPPLICATION TO PROCEED IN DISTRICT COtJRT WITHOUT PREPAYING FEES OR COSTS (Short Form) a iaintiff or petitioner in this case and declare that I am unable to pai 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 of perjury: 1. If inccirceratei I am being.held at (7irin (/2ixx) 2 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. If not incarcerated. If I am employed, my employer's name and address are: My gross pay or wages are: $ 0, and my take-home pay or wages are: $ C) per (peczfy pay period. 3. Other fncome. In the past 12 months, I have received income from the following sources (check all that apply): (a) Business, profession, or other self-employment Yes 54; (b) Rent payments, interest, or dividends Yes L4 (c) Pension, annuity, or life insurance payments Yes (d)'Disability, or worker'S compensation payments Yes (e) Gifts, or inheritances Yes () Any other sources DYes No ilfyou ans'ered Ye"to any question above, describe below or on separate pages each source ofmoney and state the amount that you received and what you expect to receive in the future. I A0 240 (Rev. 06/09) Application to Proceed in Disict Court Without Prepaying Fees or Costs (Short Form) 4. ount of money that I have in cash or in a checldng or sangs account: $ 0 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 valie held in someone else'.s name (describe the property and its approximate value): j d2r2t t2jti h) VJOvv'Thqt JLL Ro{ r t'i u,J- -' ' ') /) 'K AJA ') L' V#Jjjj Any housing, transportation, utilities, or loan payments, or other regular monthly expenses (describe andprovide 6. the amount of the ironthly expense): /l/12-v-14), TY)f-/4Jf 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: Aou vi iu MA, /, _ /JOt-) ?b 2)) 8. Any debts or financial obligations (describe the amounts owed and to whom they are payable): (jOWd L1" Declarcthon. 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: Applicant's signature Printed name