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

J _ L I Case 1 :07-cv-00108-Gl\/IS Document 1 Filed 02/22/2007 . Page 1 of 2 . l R
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Ii DELAWARE Bev. QQ ‘ ` . ` l ' ' - ~ . - ~ i
UNITED STATES DISTRICT COURT
D DISTRICT OF DELAWARE
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_ Plaintiff E APPLICATION TO PROCEED
fr,-) , .»\ ..__ V. { . {tv WITHOUT PREPAYINIEN T OF
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( we mtg iggenr széjlieet . xii dt ij, FEES AND AFFIDAVIT
A ef ndant(s) ,,_ _ .
t `P CASE NUMBER; "" 0 7 1 O 8 ni
I, l 6 declare that I am the (check appropriate box)
° ° Petitione ovant ° ° Other I L E D . l
in the above-entitled proceeding; that in support of my request to proceed without pre aym i ti f iees o co tsi i
28 USC §19l5, I declare that] am unable to pay the costs of these proceedings an that am `tl A elle
sought in the complaint/petition/motion. ‘ E EB _ `
" 111 Support of this application, I answer the following questions under penalty of perj n · I l ' CT F E WAH . _
1. Are you currently incarcerated? ©Y es ° °No [If "No" go to Question 2) _
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. If "Y`ES" state the place of your incarceration Ukllhkp _ Y lull _ Y 5
Inmate Identiiication Number (Required): Q l {5 l Q"
Are you employed at the institution? EQ Do you receive any payment from the institution? l `lg I
l Attach a ledger sheer Qom the institution of your incarceration showing at least the gas! six months '
transactions p -
2. Are you currently employed? ° ° Yes @{0 — _ -
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. Ifthe answer is "NO" state the date of your last employment, the amount of your take-home 1.
salary or wages and pay period andthe name and address of your las ploye . Y\,/vg-hg S A ttlpt
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SMB? 300 W Ops §,·la~eel” u..nl··~·» ,· DE l°`l itil $§il.()U>l*g‘;io A- ws
3. . In the ast 12 t elve months have you received any money from any ofthe following ources?
a. Business, profession or other self-employment · • Yes · · No
b. Rent payments, interest or dividends l P • • Yes • • No
c. Pensions, annuities or life insurance payments • • Yes • • No
d. Disability or workers compensation payments • * Yes • • No `
e. Gifts or inherltanees · · Yes · · No
f. An other sources _ Gibzs • • No ` Mm
. Gi`l¤»i¤tgr·u;m §cn'l" on ones; Drclqr. {lm dO[|,,fg$ZQ Qegpgry gp ta.) HN
If the answer to any ofthe above is "YES" describe each so rce of money - sta the amount »
received AJQD what you expect you will continue to receive.

v_ _p Case 1:07-cv-00108-GIVIS Document 1 Filed 02/22/2007 Page 2 of 2
I AO1411 Reverse (Rev. IOYCG) .
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I l -4- Do you have any cash or checking or savings accounts? · • Yes @0
! If "Yes" state the total amount $ ‘
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i 5. Do you own a.ny real estate, stocks, bonds, securities, other financial insmients, automobiles or other
_ valuable property? ‘
• · Yes ®Io
` If "Yes" describe the property and state its value.
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i 6. List the persons who are dependent on you for support, state your relationship to each person and
I indicate how much you contribute to their support, OR state NONE if applicable.
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‘ _ I declare tmder penalty of pe1jury that the above information is true and correct.
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i Qxl l-C>`/ - .0/l/° IAJCUM/QiL.» e
DATE - SIGNATURE OF APPLICANT .
NOTE 'I'0 PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidiavit
— stating all assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional
officer showing all receipts, expenditures, and balances during the last si; months in your institutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certiiied
statement of each account. `

Case 1:07-cv-OO108—GI\/IS Document 1-2 Filed O2/22/2007 Page 1 of 1
RESIDENT HISTORY REPORT Page 1 Of 1-
HRYCI
02/06/07 10:53
ST 006 / OPR KJG
.581 : 224512
Resident Name : WARREN, EARL L is 0 T - 1 0 8 *'“°
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 A1512 40.83 40.83
02/18/2004 12:51 Close 6 KT8 F715 40.83 0.00
04/27/2004 09:34 Reopen 6 SZG F2818 12.00 12.00
04/27/2004 09:34 Add 6 szc F2819 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 F3132 42.00 0.00
06/07/2004 17:55 Reopen 5 MDF E2557 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 E4392 32.30 33.13
10/05/2004 09:28 Close 6 KTS F6643 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 E10278 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 F14235 5.01 0.00
10/05/2005 13:34 Reopen 5 kcd E10899 1.00 1.00
06/15/2006 18:53 Add 5 CTN E15603 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 E17914 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 SED 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
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