Case 6:15-cv-01780-TC

Document 1

Filed 09/21/15

Page 1 of 3

UNITED STATES DISTRICT COURT

DISTRICT OF OREGON
EUGENE
DIVISION

0 ~t>ott..AH tf't ~tJ frz.-1 scJI

Civil Case No. (.t

\Sc.v<b\)~<J) ....,.C.

(to be assigned by Clerk of the Court)

(Enter full name of plaintiff(s))

APPLICATION TO PROCEED
IN FORMA PAUPERIS

Plaintiff(s),

v.

err; a{ {""'~_) La..tu- co v /)~->

6 w ~ 6\ Soofl5or s /:.-1 <-J A..s c.~~--> CO
(Enter full name o/ALL de}Jmdant(s))

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.

In support of this application, I answer the following questions:

1.

@Yes D No

Are you currently incarcerated?

If "Yes" state the place of your incarceration:

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.

Are you currently employed?

a.

D Yes No D Self-employed

Ifthe answer is "Yes," state:

Employer's name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _-,-_ _ _ _ _ _ _ __
Employer's a d d r e s s : - - - - - - - - - - - - - - - - - - - - - - - Amount of take-home pay or wages: $_ _ _ _ _ per _____ (specify pay period)

Revised August 6, 2010

Page 1

USDC - Oregon

Case 6:15-cv-01780-TC

b.

Document 1

If the answer is "No," state:

Nameoflastemployer:
Address of last employer:

Page 2 of 3

()

VnJV-.e/~1--r; of rTr/l_Q(lo-fv <- ~ QrVJ fie tL.. 0 (' 0--

Date oflast employment:

IYl "-~ L...oo-6

Amount of take-home salary or wages: $

3.

Filed 09/21/15

() 1 () II

c)

cr-

per

(specify pay period)

Is your spouse or significant-other employed? DYes DNo Dself-employed ~ot applicable

If the answer is "Yes," state:
Employer's name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Employer's address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Amount of take-home pay or wages: $_ _ _ _ _ per _ _ _ _ (specify pay period)

4.

In the past 12 months have you received any money from any of the following sources?

a.

Business, profession or other self-employment DYes

If"Yes," state: Amount received:
Amount expected in future:

b.

If"Yes," state: Amount received:

Disability or workers compensation payments

If"Yes," state: Amount received:
Amount expected in future:

$--------------------0

$ _________________
$ ----------

l":ii'Yes DNo
~
$ I .J I d' rJ
$

==C)
=::{_:=n==~==j"===/:t=l=lt==C o--

DYes JBNo

If"Yes," state: Amount received:

$ ________________

Any other sources

If "Yes," state: Source:

Revised August 6, 2010

Page2

011"w~/rt1

-f:.

$'6 c.../ c-,/ $.t...c...'-f I f

Gifts or inheritances

Amount expected in future :

f.

No

---------------------

Pensions, annuities, or life insurance payments DYes

Amount expected in future:

e.

$ -----------DYes

If "Yes," state: Amount received:

d.

------------

Rent payments, interest, or dividends

Amount expected in future :

c.

"No

'

1:J./

f.A..f p.

$ ________________
DYes '18;(No

--------------------------------------

Amount received:

$ ________________

Amount expected in future :

$ ________________

USDC - Oregon

Case 6:15-cv-01780-TC

Document 1

Filed 09/21/15

Page 3 of 3

LANE COUNTY CORRECTIONS

Re sident Account Summary
Monday, September 14, 2015 @11:45
For AIRS ID : 1675174

FRISCH , DEBORAH ELLEN

Transaction Description

Date

Amount

Balance

Owed

Held

Reference

-------------------------------------------- ------------- ----------------- ------ -----------------------02/19/2015

02/19/2015
12/23/2010
1 1 /12/2010
11/02/2010
10 /2 7/2010
10/25/2010

<PAST RENT>
DEPOSIT CAS
PAST RENT
CCC RENT
EPR
DEPOSIT CAS
CYBERSUITE

Payment for PAST RENT on

BOOK IN
ESP CONTRACT 12/23/10
ESP FEES 21569
OID:100031225-CornisaryPur
BQOKING IN
90486416

-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

I certify that this is a true copy ~f Deborah E. Frisch's trust account.

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