Free Motion for Leave to Proceed in forma pauperis - District Court of Delaware - Delaware

I Case 1:07-cv—00157-Gl\/IS Document 1 Filed 03/19/2007 Page 1 of 2 1
AO 2~l0(Rev. I0/03)
DELAWARE gev. 4/05]
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
EQU.--3 l l ir LL [ 5
J riamtirr APPLICATION TO PROCEED
. . ,, V. _... _ VVITHOUT PREPAYMENT OF
-* LI (lb { U FEES AND AFFIDAVIT .
Defendant(s) i , - -1
_ CASE NUMBER: O 7 1 5 7
I, l l [ [Jl L L" ( 3 declare that I am the (check appropriate box)
M.,
° ° Petitioner/Plaintiff/Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without pre ayment of _ e •· · der
28 USC §l915, Ideclare that I am unable to pay the costs of these proceedings and at am en 1 e 0
sought in the complaint/petition/motion. _ . r _
"r.#tl~. · li {Till.?
In support of this application, I answer the following questions under penalty of perj 1 U_S_ Dtsmfm- COURT
. . . DISTRICT OF
1. Are you currently incarcerated? ° °No (If"No" goto ues 1 " ‘ ` BE WARE
' . J
_ I _\ . . __,L_ g @5:am:
If "YES" state the place of your incarceration / In (C2 . I J p I?.
I {-_` ` ·. C}-
Inmate Identiiication Number (Required): , l Q C) l
. dt
Are you employed at the institution?/JC; Do you receive any payment from the institution? gxcf A
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast six months'
transactions
2. Are you currently employed? ° ° Yes ` ° No
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a
and give the name and address of your employer.
b. If the answer is "NO" state the date of your last employment, the amount of your take-home
salary or wages and pay period and the name and address of your last employer.
3. In the past 12 twelve months have you received any money from any of the following sour ?
a. Business, profession or other self-employment • • Yes •
b. Rent payments, interest or dividends • • Yes • • No
c. Pensions, annuities or life insurance payments • • Yes • • No
d. Disability or workers compensation payments • • Yes _• • No
e. Gifts or inheritances • • Yes • • No
f. Any other sources • • Yes • • No_
,/
If the answer to any of the above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.

Case 1 :07-cv-00157-GIVIS Document 1 Filed 03/19/2007 Page 2 of 2 _ `
AO 240 Reverse (Rev. 10/OG)
DEI.AWAREtRev. 4/05 .
l 4. D0 you have any cash or checking or savings accounts? • • Yes ygv
If "Yes" state the total amount S ‘
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, auton1oEsl$s or other
valuable property? ‘ rl
• • Yes · •N=
If "Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how much you contribute to their support, OR state NONE if applicable.
I declare under penalty of perjury that the above information is true and correct.
) ?»-’\.~.7;.?<
V 1 · 7 R _- lf /__
F) Qi,} 7;. { A A 5- / /"/r Q/7
DATE - / GNATU OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.

Case 1:07-cv-00157—GI\/IS Document 1-2 Filed 03/19/2007 Page 1 of 1
RESIDENT HISTORY REPORT Page 1 of 1
mzyci ""07"157—
O3/13/07 13:26 ‘
ST 006 / OPR KJG IC
X .- , —. { .~—;
SBI : 564869 I I {UU
Resident Name : ELLIS, DARYL T " `
Time Frame : 04 01 0 02:1 - 7 : ··—¤-·=—--—---·-~-·
/ /20 6 5 O3/13/2°° 13 26 U.S.DIS`I'E%.lC¢`COUHT
...,..........._..................................._.._.._.________ · _ DISTFH TO l H; ‘
Date Time Type ST OPR Receipt # Amount Balance
04/01/2006 02:15 Intake 5 mjb E14243 2.00 2.00
04/04/2006 08:30 Order 2 DDT B109005 1.77 0.23
06/19/2006 13:23 Add 7 jmh G10459 25.92 26.15
06/23/2006 15:15 Rec Payment 7 jmh G10495 4.00 22.15
06/28/2006 09:33 Order 2 DDT 8121761 21.86 0.29
07/26/2006 09:06 Order 2 DDT B125883 0.13 0.16
07/28/2006 13:52 Credit 2 DDT B125916 0.13 0.29
08/04/2006 14:11 Close 6 bsp F20857 0.29 0.00
10/25/2006 11:27 Reopen 6 kjg F22785 0.00 0.00
10/26/2006 14:21 Close 6 kjg F22822 0.00 0.00
12/03/2006 17:00 Reopen 5 BVS E18766 0.01 0.01
02/16/2007 12:29 Add 4 gmw D63926 30.00 30.01
02/21/2007 09:38 Rec Payment 10 bsp J8533 0.25 29.76
02/26/2007 14:04 Order 2 AFC B157111 28.90 0.86
03/13/2007 09:16 Order 2 DDT B159076 0.79 0.07