I I
FORM TO BE USED BY A PRISOILIEF FILIIVG AN
APPLICA TION TO PROCEED IN FOR/1.6;, PA UPERIS
IN A 42 U.5`.C. § 7983 CIVIL RIGHTS ACTION
IN THE UNITED STA TES DIS TRIS? COURT ·
Foe me ois..1·ict or DELPMMRQ- .
A L I. CAPTIOIV
G- Le ke wt ~ Ave e-
· (Entert the full name of plaintiff or O T T 1 O
piaintiffsi J "
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U. gt Aattmqs, {TNQ Drsiwmcnl Dggmiap ¤.%¢&·
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(Enter the full name of defendant or no
defendantsI N
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Instructions: -—**-
. "?T
The caption of this application should be identical tc tn: caption of the complaint. Aw
separate application must be completed by each plaintifr listed in the caption. Show yeitir rr
full name in the first line of the declaration belo vv. Provide all information requested.
( ; I II. DECI.Al'—?,iTiOi1 ,
[I {ygiir ngmgj M R GT W`, UQCIETEE ITIS? 1/ EITI l`l'lE Dl5ll'lTl.7CT li'?
the above—captioned 42 U.S. C. _§ 7999 civil right; action and that lan; entitled to proceed
Q forma gauperis pursuant to 28 U.S.C. E 7975 because of my inability to prepay the full
fee to file this action or give security therefor. l understand that the granting of Q fairy, I
gauperis status does not vvaive payment of the full filing fee. 1
In further support of this application, l pro vide the follovving information; i [
7. Do you presently have prison employment? yes I I nwf
I 2. if you are not employed do you have other incomeV yes l I no if
9. if "yes " to either of above, state source of monthiw income and amount.
source _g__ amoun t
4, if "no, "state date andplace of last employment ant: amount of monthly income.
date and place 1 ___g amount
5. Do you have money in e prison account? yes: I I amount`?_`B~YJt} _
6. Do you have money in a bank account? yes I ’ nc I I amount
7. Do you ovvn or have an interest in valuable properr such an automobile
real estate, stocks, or bonds? yes i I no
if "yes, " describe property value
Case 1 :07-cv-00110-SLR Document 1 Filed O2/22/2007 Page 2 of 2
8. List the persons who depend on you for support, state their relationship to you, and -
how much you contribute towaro their support. ·
1 ml 1p_1\}g;__ 1 V V
9. State whether you have received within the past 72 rnonths any money from any of
the fo//owing sources:
a. Business, profession or other form of se/fernpioyrnent yes ( l no i
. I I _ 1 1 `
o. i-Tent payments, interest or dividends yes l i no { M
c. Pensions, annuities {of lite insurance pa yrnen ts yes ( I nof 1
i d. Gifts or inheritances yes f l no tA/
I
e. Any other sources 1 yes ./l no ( l ·
if the answer to any of the above is "yes, ’“ describe each source of money I
ano’ state the amount received from each source ouring the past ii months. A
1 if
I I
iii. DECLAHA TION AND SIG/UA TUBE
/ deciare under penalty o t periu ii ·· he foregoing is true and correct,
I { l
J 1 . i/ _?
} *91 i r
SlGiVA TUHE OF FLAIIVTIFF DA TE
I IV. CERT/PICA TION 1 _
instructions:
Request that an appropriate prison official provide: 7 l the information be/ow concerning
your inmate trust fund account balances; and 2} a cer‘tifieo’ copy of your inmate trust fund
account statement snowing a/J deposits and withdrawals for the prio· six—mon th period.
1 1 1 {T-. = -
/ certify that the applicant named herein has the sum of ` on account
to his credit at the ty 5 a Et r"` is , institution where he is
confined. fl VI 1*;% ‘*.,1_ —..,.
/,/"""£ ' , 1
l further certify th/atâ€o’uring= the last six months the a1;Jplicant's--a vera oe monthly account
ala-nee was 5 / _ , ,4 and that the averape monthly deposits during the during
the last six.n·1on't’hs were F _j 1
J _ Z
i .=. . or 1 · t
I l &I"=i`I E I l\r}II;lgT ) is "" {J W"' it ‘·
\ /'E' g`a_.·-?}`*?§YT·_’
S; —MRt5’AlIlD TlTL5 OFAir’THOf?lZED OFF/C/Aj DA TE
Page 2
Case 1:07-cv-00110-SLR Document 1-2 Filed O2/22/2007 Page 1 0f 2
‘ MOSHANNON VALLEY
Resident Account Summary {E 7 F 1 Q
Monday, November 20, 2006 @l5:32 M ’ M ` "—*
For CIN: 82074054 AWALA, GBEKE
Date Transaction Description Amount Balance Owed Held Reference
09/12/2006 INMHTE PAYR [email protected] STUDENT 0.96 3.00 0.00 0.00
09/07/2006 INMATE PAYR PPAY - Education l 2.04 2.04 0.00 0.00
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Page 2
Case 1 :07-cv-001 10-SLR Document 1-2 Fnled O2/22/2007 Page 2 of 2
MOSHANNON VALLEY
Sent Order 100016675 for AWALA, GEEKE
Monday, November 06, 2006 @10:27
ID Order # Name `
82074054 100016675 AWALA, GEEKE
Order Date Location _ Order Form
2006-10-30 1 216 114LD SHU - AD `
Alias Description Qty Price Extend Tax Total Status
1050 BOOK OF TEN STAMPS 3 3.90 11.70 0.00 11.70 Sent ,
7047 NORELCO T500 TRIMMER 1 22.19 22.19 1.33 23.52 Sent
3231 SL OATMEAL SANDWICH CAKES 1 2.80 2.80 0.00 2.80 Sent
3236 SL SWISS RLLS BX-6 TWN PK 1 2.50 2.50 0.00 2.50 Sent
3274 ICED HONEY BUN 6OZ 2 1.10 2.20 0.00 2.20 Sent
4020 PAYDAY 1 0.80 0.80 0.00 0.80 Sent
_ 4000 M&M PLAIN l 0.80 0.80 0.00 0.80 Sent
1 3112 SALTINE CRACKERS 1 1.95 1.95 0.00 1.95 Sent _
i 6349 WHOLE ENCHILADA PARTY MIX 1 1.70 1.70 0.00 1.70 Sent
6673 RICE NOODLES 2 0.55 1.10 0.00 1.10 Sent
6001 SHRIMP RAMEN NOODLES 2 0.45 0.90 0.00 0.90 Sent
6015 ROAST CHICKEN RAMEN 2 0.45 0.90 0.00 0.90 Sent
6050 7OZ RICE ZIPPER 1 1.50 1.50 0.00 1.50 Sent
6178 FC MACKERAL 1 1.50 1.50 0.00 1.50 Sent
6181 FC SARDINES/TOMATO SAUCE 4 1.20 4.80 0.00 4.80 Sent
6770 BF SUMMER SAUSAGE ORG FLV 2 1.90 3.80 0.00 3.80 Sent
6410 GRAPE JELLY 1 2.15 2.15 0.00 2.15 Sent
6424 CC JALA CHS SQUEEZER 16OZ 1 2.75 2.75 0.00 2.75 Sent
2028 KF TEA BAGS 48 COUNT 1 2.50 2.50 0.00 2.50 Sent
6520 KROG OATMEAL VARIETY PACK 1 3.00 3.00 0.00 3.00 Sent
1203 ION3 AA 2/PK 1 1.69 1.69 0.10 1.79 Sent
1015 MANILLA ENVELOPE 10 0.15 1.50 0.09 1.59 Sent
‘ 1060 8.5 X 11 LETTER PAD WHT 1 0.95 0.95 0.06 1.01 Sent
1061 8.5 X 11 LETTER PAD YLW 1 0.95 0.95 0.06 1.01 Sent
1121 SEASONAL GREETING CARD 2 0.90 1.80 0.11 1.91 Sent
1109 FRIENDSHIP CARD - PAPER 1 0.90 0.90 0.05 0.95 Sent
0040 MAGNIFICENT HAIR FOOD 1 3.20 3.20 0.19 3.39 Sent
0205 4OZ BABY OIL 1 0.80 0.80 0.05 0.85 Sent
0397 NEXT1 COCOA BTTR SOAP 5OZ 2 0.90 1.80 0.11 1.91 Sent
0763 Q-TIPS 30/CT 1 0.90 0.90 0.05 0.95 Sent
3200 BANANA MARSHMALLOW PIE 1 0.55 0.55 0.00 0.55 Sent
6127 HOT SPICY PORK RINDS ` 2 1.05 2.10 0.00 2.10 Sent
0355 15OZ VOLUME SHAMPOO 1 2.10 2.10 0.13 2.23 Sent
ivuz¤’— L 1 2-59 450 U-15 2-65 SEM
hxmi0251_ TOLNAFATE ANTIFUNGAL CREA * 1 2.00 2.00 0.12 2.12 Sent
».m4.¤ 1 2.50 2.50 0.15 2.55 Sent
Nuwk0271 BLISTEX LIP OINTMENT l 2.50 2.50 0.15 2.65 Sent
nmbL02504WHYDROCORTISONE CREAM 1 1.95 1.95 0.12 2.07 Sent
m·,1_025§""`I11501c‘z1·1·50 ouest RUB 5 oz 1 2.50 2.50 0.15 2.65 sem;
ma 0_ iBANDAGE ’1`0‘/5x_;j5AN1>A 1 1.00 1.00 0.05 1.06 san:
wuL0289;iIEOPROFENr200MG 1 2.50 2.50 0.15 2.65 Sent
¤¤¤L0662 ALLERGY TABLETS_24CT 1 2.50 2.50 0.15 2.65 Sent J
ma. 0655 STR5TE_.ETS‘-EI-CEUID 0oz. 1 3.20 5.20 0.19 5.55 sent
~¢;L0669-`SAIINEi§§SAL SPRAY 1.502 1 1.80 1.80 0.11 1.91 Sent
nug0641 ROLAIDS ORIGINAL FLAVOR l 1.25 1.25 0.08 1.33 Sent
_ T0_l_0_#Â¥1i0rWHITE'ENVELOPE 20 0.05 1.00 0.05 1.06 55;.5
I wnLQE74m_HALLS CHERRY_CQU§H DROPS l 0.90 0.90 0.05 0.95 Sent
1 1051 BLACK-VPEN-FPLASTECLIPJ 1 0.25 0.25 0.02 0.27 sam
I 1092 BLUE PEN (PLASTIC CLIP) 1 0.25 0.25 0.02 0.27 Sent
I Order Total 119.38 4.06 123.44
Alias Description Qty Price Extend Tax Total Sent
0250 HYDROCORTISONE CREAM 1 1.95 1.95 0.l2 2.07 No
Refund Total 1.95 0.12 2.07
Category Max Limit Current Funds Available
Order Form Max Limit ($909.40) 909.40 0.00 1.75
Commissary Items 290.00 0.00
phone time 556.00 0.00
;!iJ¥—
Page 1
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