ARIZONA DEPARTMENT OF L JECTIONS
Protective Segregation - Inmate Statement .
inmate Name {mi, i=rm¢.w.i.i ADC Number
E PJ L! G . $2/
Institution! Unit
/5 0 67
STATEMENT:
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Inmate Sign re Date
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ness Signature Date
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Case 2:04-cv-00323-FJIVI Document 70-3 Filed 10/13/2005 Page 2 of 2 mm,
· Am: 022 ““°’°`
Case 2:04-cv-00323-FJM
Document 70-3
Filed 10/13/2005
Page 1 of 2
Case 2:04-cv-00323-FJM
Document 70-3
Filed 10/13/2005
Page 2 of 2