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

Case 1:07-cv-00061—G|\/IS Document 1 Filed 01/29/2007 Page 1 of 2
FORM TO BE USED BY A PRISONER FILING AN I ~
APPLICA TION TO PRO SEED IN FORMA PA UPERIS ‘
IN A 42 U.S.C. § 7983 CIVIL RIGHTS ACTION V
IN THE UNITED S TA TES DISTRICT COURT; I ’
FOR THE " Dull; ..i1lCT OF [>E·L¢\wv°d<`£C V, i
. I. GAPTION I I
Qkgkg VM - .
· {Enter the full name ot plaintiff or E V A '
plaintiffs} _, _ V
V. U 1 ` V O T W ' 6 1 _r,` ;
(Enter the full name ot defendant or . ‘ _ _ V “ · ··‘;_ V V
¤'¤f¤¤d¤¤t¤l , I _. .. .. anaa Q; LU 4 j
$2 V . . SVVVVN4, V
Instructions: - RV V
The caption of this application should be identical to the caption of the- complaint. A l
r separate application must be completed by each plaintiff listed in the caption. Sho vv your
full name in the first line of the declaration below. Provide all information requested. V
V V L V ll. DECLARATION l ‘
V` l, (your name) ` hdeclare that l am the plaintiff in
` the above—captioned 42 U. S. C. § 7983 civil rights action, and that l am entitled to proceed
· Q forma paugeris pursuant to 28 U. S. C. E- 7975 because ot myinability to prepay the full
tee to file this action or give security therefor. l understand that the granting oi Q forma
gaugens status does not waive payment ot the full tiling fee. .
ln further support of this application, l provide the to/lowing information:
l. Do you presently have prison employment? T yes ( I no __;,I-/"
I 2. lf you are not employed do you have other income? ·- yes ( I no if U i ‘
3. lf "yes" to either of above, stateV source ot" monthly income and amount. . I
source ` V . amount
4. ll "rio, " state date and place ot last employment and amount of monthly income. I
date and place ‘ n l amount
5. Do you have money in a prison account? yes V7 no I J am unt O ·’ /6
6, Do you have money in a bank account? yes ( } ¤t.»#,>l%gu¤z
7. Do you ovvnror have an interest in valuable property such an automobile
real estate, stocks, or bonds? 1 yes I } no/VK
lf "yes, " describe property value

V I Case 1:07-cv-00061—G|\/IS Document 1 Filed 01/29/2007 Page 2 of 2
' * I
I 8. List the persons who depend on you for support, state their relationship to you, and · _
hovv much you contribute toward their support. _g ·
I G§»v@>-·Ii’$’—·$<>"~**·°’#’>* @*7*}* -· » ·
. · · _ I
.9. State whether you have receiveo’ within the past 7 2 months any money from any of
the folio wing sources: ‘ I
a. Business, profession or other form oi se/f—employrnent yes { ) no { -
I Ib, Rent payments, interest or dividends yes { I no l I
c. Pensions, annuities —ior lite insurance payments yes { } no Lan I
· d, Gifts or inheritances YES l// no l }_ -
I
_ e. Any other sources , ‘ , yes { I no _;/V · _ I I ·
lf the answer to any of the above rs ”yes, ” describe each source of money I I
_. and state- the amount received from each source during the past 72 months. _
I\_ ‘ I Ill. DECLARATION AND SIGNA TUBE I I
(2 U ' { I I .
I _ l dec/are under penalty of eijury that the foregoing is true and correct. I
. I SlG/\iA TUHE OF PLAli\iTlFF · DA TE
s I IV. CERTIFICATION I ,
Instructions: I · _ _ r U I
I Request that an appropriate prison official provide: 7} the information below _cohcerningI I
your inmate trust fund account balances; and 2} a certified copy of you inmate trust fund
account statement showing all deposits and withdrawals for thetoriorjsfx-month period. ‘ I
. l'\ _ ‘ ._ g I I ;t I
lcertify that the applicant nam oI\herein h s he sum of *5 I ;I E on account I
to his credit at the 5 i · " " institution where he is {
- confined. ‘ F V ” { . g
i further certify thal‘IUuFr1gath?Ilast six months the applicants average monthly account I
ba/ance was I ) `~·i ; and that the average monthly deposits during the during I
the last s' -com-oriths were'$ it · _ .
/IX L-V--— I —_`—;__7T’_ - q I
/ I/III \ I/EI " II ‘ I {
“· 1 y _» I I ‘·I · ” " » no
I \\"—-___ i/T -_.-M- \ iq fl " III
_SlG/\/- \EIOFi·éIu./I _ O FlC/AL DA TE I , ____,,/2 I
Q.,/' I
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r Page 2 .
. I I

Case 1:O7-0114).0964;-QMS:---|9eeu=mea%-1-%----E|4ed=94%29%2607 Page 1 of 2
_ C MOSHANNON VALLEY
Resident Account Summary
' ` · 7 Tuesday, November 21, 2006 @08:30
For CIN: 82074054 AWALA, GBEKE
Date Transaction Description Amount Balance Owed Held Reference
11/06/2006 ERE OID:100016675-ComisaryRef 2.07 3.82 0.00 0.00
11/03/2006 SNEAKER PAYMENT -28.10 1.75 0.00 0.00
11/03/2006 PROP EPR SNEAKER PAYMENT 28.10 29.85 28.10 0.00
11/03/2006 11/03/2006 MAIL CHARGE MAIL CHARGES 4.20 34.05 4.20 0.00
11/03/2006 11/03/2005 MAIL CHARGE MAIL CHARGES 5.30 39.35 5.30 0.00
11/03/2006 11/03/2006 MAIL CHARGE MAIL CHARGES 0.00 39.35 0.00 0.00
11/01/2006 11/01/2006 MAIL CHARGE MAIL CHARGES 4.18 43.53 4.18 0.00
11/01/2006 11/01/2006 MAIL CHARGE MAIL CHARGES 1.89 45.42 1.89 0.00
10/30/2006 10/30/2006 MAIL CHARGE MAIL CHARGES 5.79 51.21 5.79 0.00
10/30/2006 EPR OID:100016675-ComisaryPur -123.44 51.21 0.00 0.00
10/26/2006 DEPMO J FEDNANDEZ #55764932707 100.00 174.65 0.00 0.00 Q 'T -- ; 6 1 I
10/25/2006 DEPMO EVELYN #48663689679 50.00 74.65 0.00 0.00 `
10/24/2006 30 COPIES MADE ON 10/19/0 -3.00 24.65 0.00 0.00
10/24/2006 COPY CHRG 30 COPIES MADE ON 10/19/0 3.00 27.65 3.00 0.00
10/24/2006 21 COPIES MADE ON 10/19/0 -2.10 27.65 0.00 0.00 $
10/24/2006 COPY CHRG 21 COPIES MADE ON 10/19/0 2.10 29.75 2.10 0.00 __ __%*Wf {
10/23/2006 EPR 010:100015679-ComisaryPur -25.05 z0.v5 0.00 0,00 1C‘”“r*“rtt*tt5···”Q,Ljg
10/20/2006 78 COPIES MADE ON 10/13/0 -7.80 63.61 0.00 0.00
10/20/2006 COPY CHRG 78 COPIES MADE ON 10/13/0 7.80 71.41 7.80 0.00 0 $2;i::::;i§ _p
10/20/2006 ERP OID:100014711-ComisaryRef 3.90 71.41 0.00 0.00 1 1 1Â¥ _... $0
10/16/2006 EPR OID:100014711-ComisaryPur -83.01 67.51 0.00 0.00 ;,» E ha %?;QW '`‘`
10/11/2006 JPAY DEP JPay Deposit from JOE KAL 100.00 150.52 0.00 0.00 `*>1 ——-` EQ §77C§
10/10/2006 COPY CHRG VOID-81 COPIES -8.10 50.52 0.00 0.00 { *f{ @~ y.`“`
10/10/2006 COPY CHRG VOID-29 COPIES -2.90 50.52 8.10 0.00 1A 1 CU ;`~"
10/10/2005 com 0000 v010-50 000100 -5.00 50.52 11.00 0.00 N 1
10/10/2006 COPY CHRG VOID-36 COPIES -3.60 50.52 16.00 0.00 Lf .1 EE iijof
10/10/2000 COPY CHRG VOID—92 COPIES -9.20 50.52 19.60 0.00 §¤1:¥ fg @y,§;
10/10/2006 COPY CHRG VOID-97 COPIES -9.70 50.52 28.80 0.00 ; 1 ?p§j®
10/10/2006 COPY CHRG VOID-10 COPIES -1.00 50,52 30,50 0,00 I ;2l___q__w_“ '; 1.;;;-
10/10/2006 COPY CHRG VOI0—55 COPIES -5.50 50.52 3,0.50 0,00 1 IJ ‘1‘‘1‘ 1 no 0000 1 j}
10/10/2006 VOID-81 COPIES 8.10 50.52 45.00 0.00 1 *
10/10/2006 VOID-29 COPIES 2.90 42.42 36.90 0.00 1--- -~-- -~-CLL -—--·»- ~~-
10/10/2006 VOID-50 COPIES 5.00 39.52 34.00 0.00
10/10/2006 VOID-36 COPIES 3.60 34.52 29.00 0.00
10/10/2006 VOID-92 COPIES 9.20 30.92 25.40 0.00
10/10/2006 VOID-97 COPIES 9.70 21.72 16.20 0.00
10/10/2006 VOID-10 COPIES 1.00 12.02 6.50 0.00
10/10/2006 VOID-55 COPIES 5.50 11.02 5.50 0.00
10/06/2006 INMATE PAYR PPAY - Education 1 0.36 5.52 0.00 0.00
10/02/2006 EPR OID:100012332-ComisaryPur -52.84 5.16 0.00 0.00
09/29/2006 81 COPIES -8.10 58.00 0.00 0.00
09/29/2006 COPY CHRG 81 COPIES 8.10 66.10 8.10 0.00
09/29/2006 29 COPIES . -2.90 66.10 0.00 0.00
09/29/2006 COPY CHRG 29 COPIES 2.90 69.00 2.90 0.00
09/29/2006 50 COPIES -5.00 69.00 0.00 0.00
09/29/2006 COPY CHRG 50 COPIES 5.00 74.00 5.00 0.00
09/29/2006 92 COPIES -9.20 74.00 0.00 0.00
09/29/2006 COPY CHRG 92 COPIES , 9.20 83.20 9.20 0.00
09/29/2006 36 COPIES -3.60 83.20 0.00 0.00
05/29/2005 COPY CHRG 36 COPIES 3.60 86.80 3.60 0.00
09/29/2006 97 COPIES -9.70 86.80 0.00 0.00
09/29/2006 COPY CHRG 97 COPIES 9.70 96.50 9.70 0.00 _
09/29/2006 10 COPIES -1.00 96.50 0.00 0.00
09/29/2006 COPY CHRG 10 COPIES 1.00 97.50 1.00 0.00
09/29/2006 55 COPIES -5.50 97.50 0.00 0.00
09/29/2006 COPY CHRG 55 COPIES 5.50 103.00 5.50 0.00
09/29/2006 JPAY DEP JPay Deposit from JOE KAL 100.00 103.00 0.00 0.00
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Case 1 :O7-cxeQ.0.(16J££5.l1/LSe::JZ1ee4.u11.em.LJs.2s===Eile:1:Q.LL29.é20.07 Page 2 of 2
E 7* * MOSHANNON VALLEY
x _ W x Resident Account Summary
Tuesday, November 21, 2006 @08:30
For CIN: 82074054 AWALA, GEEKE
Date Transaction Description Amount Balance Owed Held Reference
09/12/2006 TNMATE PAYR [email protected] STUDENT 0.96 3.00 0.00 0.00
09/07/2006 INMATE PAYR PPAY - Education 1 2.04 2.04 0.00 0.00
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