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

Q ~ Case 1:07-cv—00121-Gl\/IS Document 1 Filed 02/27/2007 Page 1 of 2 . `
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
_ Pramtra ‘ APPLICATION TO PROCEED
g _ V. . WITHOUT PREPAYIVIENT OF
. , · FEES AND AFFIDAVIMT
Defendant(s) 1; O 7 ’] 2 ']
" CASE NUMBER;
I, * l` ` I l declare that I am the (check appropriate box)
° ° Petitioner/Plaintiffdviovant ° ° Other l
C) 3( RJ-l(Y"1
inthe above-entitled proceeding, that in support ofmy requestto proceed without pre · · - - - _· ··-—. ·‘
28 USC §l915, I declare that I am unable to pay the costs ofthese proceedings and · at I am e I? =- _' _
sought in the complaint/petition/motion. _'
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‘ In Support of this application, I answer the following questions under penalty of perj '_ : g In 1 __ J; _j .
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l. Are you currently incarcerated? es °No (If"No" go to +j_¤uestrqgi§§ |{j QFQELAWARE 1
` .r'·-... . - - l
. If "YES" state the place of your incarceration 'lili · · x. "
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Inmate Identification Number (Required):
Are you employed at the institution? t· Do you receive any payment from the institution? Il A
n Attach a ledger sheet Qom the institution ot your incarceration showing at least the gast six months'
transactions _ J , -
2. Are you currently employed? G-Yes A ·
a. Ifthe 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. Ifthe answer is "NO" state the date of your 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 of the following sources?
a. Business, profession or other self-employment · · Yes f°·_ _No
b. Rent payments, interest or dividends l · · Yes Z · No
c. Pensions, annuities or life insurance payments • • Yes if • 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 ofthe above is "YES" describe each source of money and state the aniount
received AND what you expect you will continue to receive. : . C y . · .
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. Case 1 :07-cv-00121-GIVIS Document 1 Filed 02/27/2007 Page 2 of 2 . -
i AO 240 Reverse (Rev. 10/O3)
DELAWARE Rev. ·l/055 ‘ I .
l 4. Do you have any cash or checking or savings accounts? • • Yes f_!"‘;~No
If "Yes" state the total amount $ I l I
5. Do you own any real estate, stocks, bonds, securities, other Hnancial instruments, automobiles or other
valuable property? ‘
• · Yes • •No
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 ofperjury that the above information is true and correct.
DATE · SIGNATURE 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 sur months in your institutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certiiied
statement ofeach account.

Case 1:07-cv-00121-GI\/IS Document 1-2 Filed 02/27/2007 Page 1 of 1
RESIDENT Hxswom Rzponw Page 1 <>f 1
HRYCI
02/06/07 1.0:53
ST OO6 / OPR KJG
S81 ; 224512
Resident Name : WARREN, EARL L
Time Frame ; 01/13/2004 18:16 — 02/06/2007 10:53
Date Time Type ST OPR Receipt # Amount Balance
01/13/2004 18:16 Intake 1 Cobra Al512 40.83 40.83
02/18/2004 12:51 Close 6 KTS F715 40.83 0.00
04/27/2004 09:34 Reopen 6 SZG 82818 12.00 12.00
04/27/2004 09:34 Add 6 SZG 82819 5.00 17.00
04/28/2004 16:16 Add 6 SZG F2852 25.00 42.00
04/30/2004 12:01 Close 6 SZG 83132 42.00 0.00
06/07/2004 17:55 Reopen 5 MDF 82557 13.80 13.80
06/14/2004 11:59 Order 2 DDT 820629 12.97 0.83
09/27/2004 02:11 Add 5 CNC 84392 32.30 33.13
10/05/2004 09:28 Close 6 KTS 86643 33.13 0.00
06/30/2005 09:48 Reopen 6 kjg F12350 30.00 30.00
07/05/2005 13:48 Order 2 DDT 869962 24.33 5.67
07/08/2005 12:57 Credit 2 DDT 870453 24.33 30.00
07/25/2005 09:49 Close 6 kjg F12910 30.00 0.00
08/31/2005 23:33 Reopen 5 WAD 810278 5.01 5.01
09/06/2005 08:01 Order 2 DDT 878267 4.77 0.24
09/09/2005 14:49 Credit 2 DDT 878929 4.77 5.01
09/22/2005 13:10 Close 6 kjg 814235 5.01 0.00
10/05/2005 13:34 Reopen 5 kcd 810899 1.00 1.00
06/15/2006 18:53 Add 5 CTN 815603 30.00 31.00
06/23/2006 08:32 Close 6 bsp F19904 31.00 0.00
10/12/2006 02:58 Reopen 5 RCP 817914 73.78 73.78
10/17/2006 09:11 Order 2 DDT 8137689 33.25 40.53
10/24/2006 09:15 Order 2 DDT 8138713 25.38 15.15
10/30/2006 13:56 Order 2 WLH 8139742 12.15 3.00
11/13/2006 08:24 Order 2 WLH 8141345 2.26 0.74
11/28/2006 12:54 Add 4 J D58983 50.00 50.74
12/06/2006 10:06 Order 2 DDT 8145134 3.92 46.82
12/06/2006 11:48 Add 4 S8D D59511 10.00 56.82
12/18/2006 14:08 Order 2 WLH 8147050 23.91 32.91
12/26/2006 13:15 Add 4 SED D60767 20.00 52.91
01/03/2007 09:08 Order 2 DDT 8149030 12.19 40.72
01/09/2007 09:07 Order 2 DDT 8150056 18.67 22.05
01/11/2007 11:21 Add 4 J D61720 10.00 32.05
01/12/2007 11:06 Credit 11 WLH K2542 18.67 50.72
01/16/2007 11:02 Order 2 DDT 8151206 2.82 47.90
02/05/2007 10:22 Rec Payment 10 bsp J8138 2.00 45.90