Y AO 2¢i0(l`
DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYIVIENT OF
, _ ¤.··i:j:·. , _. `y=‘ _. 3 E ,g A 3 ·i - I Z {I; _,__. _ FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER: Civ Action O7—l46 SLR
l, gi" ` X gt gy--, \g—’· _§ E`; ij _, a. ; -i—~ declare that l am the (check appropriate box)
r Petitioner,iI"la.intifflilvlovant El Other
in the above—entitled proceeding; that in support of my request to proceed without pre m n o .•» · r qvstpryn er
28 USC §l9l 5, I declare that I am unable to pay the costs of these proceedings and hat I -·· · - ' -··- li ` f
sought in the complaint/petition/motion. ._ . l
{ " APR 9 2{"ilil Y:
In support ofthis application, I answer the following questions under penalty of perju ; ‘ B. ta
l. Are you currently incarcerated? },mYes El No (If"No" go to `! .= Y . ! ICT PF D LAW HE ·*·
If"YES" state the place of your incarceration X,-It .e ._ .·, ,“¥,... — I- »· -x .. E- . _, gi; _jt5_;r. _;`;LC_c__!
Inmate Identification Number (Required): itil? '‘-· I"·--hk .;'·;·-‘-Jréiib.
Are you employed at the institution? )‘~;·ii-? Do you receive any payment from the institution?
Attach a ledger sheet [rom the institution ot your incarceration detailing all transactions over the gas!
sb: months.
2. Are you currently employed? El Yes EI\No
a. Ifthe answer is "YES" state the amount of your take—home salary or wages and pay period
and give the name and address ofyour employer.
b. Ifthe answer is "NO" state the date ofyour last employment, the amount ofyour 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 ofthe following sources?
a. Business, profession or other self—employment Cl Yes _'`"` -
b. Rent payments, interest or dividends E1 Yes (;D__N_c>r;‘
c. Pensions, annuities or life insurance payments Cl Yes (;Q1r_No
d. Disability or workers compensation payments U Yes U No ` `‘’-- (_
e. Gifts or inheritances K1 Yes QE! "N_o" R
f. Any other sources D Yes iQ No
Ifthe answer to any ofthe 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-00146-SLR Document 4 Filed O4/05/2007 Page 2 of 3
AO 240 Reverse (Rev. iO/O3)
DELAWARE Rev5{O6
4. Do you have any cash or checking or savings accounts? Cl Yes { 'ilil No 5 y
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? _____
C1 Yes ( "`C1 No I
lf "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.
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I declare under penalty of perjury that the above information is true and correct.
H _ {Z1?. , E l ;--_i, \ ; _ l r ` l I {fi I, fir '— -I 'jgt-{1* { I K-- g"
DATE SIGNATUREOT 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-06153-SLR Document 4 Filed O4/O5gOg3 gp Page 3 of 3
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Case 1:07-cv—00146-SLR Document 4-2 Filed 04/05/2007 Page 1 of 1
RESIDENT HISTORY REPORT Page 1 Of 1
HRYCI I .
O4/O2/07 13:32 . I]
ST 006 / OPR BSP Q lr/'II
SBI : 557338
Resident Name : JONES, EMMANUEL
Time Frame : 01/29/2006 10:06 - 04/02/2007 13:32
Date Time Type ST OPR Receipt # Amount Balance
01/29/2006 10:06 Intake 5 bsf E12978 6.02 6.02
02/08/2006 05:43 Order 2 DDT B100503 5.87 0.15
05/27/2006 22:52 Add 5 lmw E15269 11.10 11.25
06/07/2006 10:24 Order 2 DDT B118583 10.89 0.36
07/21/2006 11:50 Add 4 SED D51356 150.00 150.36
07/26/2006 08:47 Order 2 DDT B125854 59.16 91.20
08/02/2006 11:02 Order 2 WLH B126817 58.20 33.00
08/07/2006 12:45 Credit 2 WLH B127185 13.58 46.58
08/07/2006 12:46 Order 2 WLH B127186 18.97 27.61
08/16/2006 08:57 Order 2 DDT B128959 1.41 26.20
08/16/2006 13:41 Credit 2 DDT B128971 1.41 27.61
08/23/2006 08:32 Rec Payment 10 bsp J5248 2.75 24.86
08/30/2006 08:10 Rec Payment 10 bsp J5258 3.15 21.71
08/31/2006 08:56 Order 2 WLH B130894 1.88 19.83
09/04/2006 11:01 Order 2 WLH B131199 13.82 6.01
09/11/2006 06:58 Order 2 WLH B132079 5.44 0.57
10/02/2006 06:42 Order 2 DDT 8134996 0.46 0.11
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