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Document 1
Filed 09/21/15
Page 1 of 3
\Sc.v<b\)~<J) ....,.C.
APPLICATION TO PROCEED
IN FORMA PAUPERIS
Plaintiff(s),
v.
Defendant(s).
f)e,ho
~ GfkYI Cry;,~
I,
f
declare that I am the plaintiff in the above-entitled proceeding;
that, in support of my request to proceed without prepayment offees under 28 U.S.C. 1915, I declare than
I am unable to pay the fees for these proceedings or give security therefor and that I am entitled to the relief
sought in the complaint.
@Yes D No
j;c;:..ru...
;i
Co V/1 '1
If "Yes" and you are filing a civil action, have the institution fill out the Certificate portion of
this application and attach a certified copy of your prison trust account showing transactions
for the past six (6) months.
2.
D Yes No D Self-employed
USDC - Oregon
Case 6:15-cv-01780-TC
b.
Document 1
Page 2 of 3
()
Filed 09/21/15
() 1 () II
c)
cr-
per
4.
In the past 12 months have you received any money from any of the following sources?
a.
b.
$--------------------0
$ _________________
$ ----------
l":ii'Yes DNo
~
$ I .J I d' rJ
$
==C)
=::{_:=n==~==j"===/:t=l=lt==C o--
DYes JBNo
$ ________________
011"w~/rt1
-f:.
Gifts or inheritances
No
---------------------
e.
$ -----------DYes
d.
------------
c.
"No
'
1:J./
f.A..f p.
$ ________________
DYes '18;(No
--------------------------------------
Amount received:
$ ________________
$ ________________
USDC - Oregon
Case 6:15-cv-01780-TC
Document 1
Filed 09/21/15
Page 3 of 3
Transaction Description
Date
Amount
Balance
Owed
Held
Reference
<PAST RENT>
DEPOSIT CAS
PAST RENT
CCC RENT
EPR
DEPOSIT CAS
CYBERSUITE
-54.00
54.00
569.08
-93 . 92
-7.08
2.00
99.00
0.00
54.00
0.00
0 . 00
93.92
101.00
99.00
9-lh{- \sSigned
Dat e
Page 1
515.08
569.08
569 . 08
0 . 00
0.00
0.00
0.00
0.00
02/19/2015
0.00
02/19/2015
0 . 00
12/23/2010
0 . 00
11/12/2010
0.00
11/02/ 2010
0 . 00
10 /27/2010
0 00 .,_ J,q/:2V2010
0