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AD·1~lO{DELAW.;1.R.E REV 7.'D0)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Plaintiff APPLICATION TO PROCEED
WITHOUT PREPAYMENT OF
V. ` FEES AND AFFIDAVIT
oetemuamts) CASE NUMBER: O T " A 4 ie "’
I, g g l la ci»·;i~e`L“, 3 _ declare that I am the (check appropriate box)
El Petitioner/Plaintiff/l\/[ovant Cl Other in the above-entitled proceeding; that in support of my
request to proceed without prepayment of fees or costs under 28 USC §l9lS, I declare that I am
unable to pay the costs of these proceedings and that [ am entitled to the relief sought in the
complaint/petition/motion. , .
In support of this application, I answer the following questions under penalty of perjury:
1, Are you currently incarceratmg Yes Cl No (If "No" go to g ii nlni lliu
If "YES" state the place of your incarceration
tltllsl 2. 2 2@@ll
Are you employed at the institution? Cl Yes lj No p `
l ittle count
Do you receive any payment from the institution? Cl Yes Cl No _,__,, 5, Jiit » »-»:
E} Srumflv tv
Hove the institution [tl! out the certijtcote portion ofthis offtdovitondottoc}1 ez ledger sheet from the _
irzstz'mtion(sJ of vow incarceration .s/towing or least the post .S`[Xm·orzths' trmzsoctions. Led? er
sheets are not reon.iree/ for crises ft/ed gitrsztont to 28:USC §225¤/.
2. Are you currently employed? I] M No
a. If the answer is "YES" state the amount of your take—home salary or wages and pay period and
give the name and address of your employer.
b. If the answer is "NO" state the date of your last employment, the amount of your tal
3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment U Yes E No
b. Rent payments, interest or dividends Cl Yes l] No ‘
c. Pensions, annuities or life insurance payments [l Yes Cl No
d. Disability or workers compensation payments Cl Yes Cl No
e. Gifts or inheritances U Yes I] No
f. Any other sources [I Yes E No
If the answer to any of the 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—00044-Gl\/IS Document 1 Filed 01/22/2007 Page 2 of 2
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4. ` Do you have any cash or checking or savings accounts? I] Yexl No
If "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or
other valuable property? I] Yes El 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 ifapplicable.
I declare under penalty ofperjury that the above infonnation is true and correct. p
Date: SQ I Signature of Applicant Jgi/6*xln Q/Lying l· gi
Case 1:07-cv-00044-GMS Document 1-2 Filed O1/22/2007 Page 1 of 2
INMATE ACCOUNT STATEMENT
LAVAR LEWIS 16-Aug-06
NAME SCCC ADMIT DATE
442722 I, O 7 ·— A 4 M ~···~
SBl# DATE RELEASED ‘
DATE bsposrrs Typc ef DISBURSE Type °f i3Ai.ANcE
Deposit MENT Disburs.
$0.00 $0.00 $0.00
1/11/2007 $171.40 $0.00 $0.00 $171.40
1.·'12/2007 $0.00 $40.00 R/B $131.40 $131.40
1.·"l2/2007 $0.00 $22.00 medical $109.40 $109.40
1.·'17/2007 $0.00 $1.50 mail $107.90 $107.90
1/17l'2007 $0.00 $0.47 law llbrafy $107.43 $107.43
1/17/2007 $0.00 $107.00 P2 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
$0.00 $0.00 $0.43 $0.43
TOTAL $171.40 $170.97 $0.43
$0.00
OPENING BALANCE `_ W
.:. 2..,....;. . . .... - ’ “ "'
Accourvr sALANcs TE { .... ........ .... .
TYPE OF DISBURSMENTS E 1 _ _- F 4 g- Q E
R/B room/board owed from previous visits to SWRU °JjAN 2' mm
MED = Visits to medical E _M_m_y mvwm mw
TRANS = transportation owed from previous visits U.S. DiSTi*L`ii}$COUFl`§' g
P2 = Pay to's submitted thru business office . .
DG = Dollar General/commissary
TRANSF Transfers to Other Institutions
SP. COURT Superior Court
TYPE OF DEPOSITS
M/O = money orders received outside of institution
B/R = booking and receivng
CK = checks
CASH
I/W = inmate wages
VIOLATION OF PROBATIONISCCC
I Case 1 :07-cv-OOO44—Gl\/IS Document 1-2 Filed O1/22/2007 Page 2 of 2 _
INMATE ACCOUNT STATEMENT
TO: Inmate Name: LQ; gl C I )
(Last) p (First) (Ml.)
SBI Number: (3 O
Housing Unit: SV
FR: Inmate Account Teclmician
DA:
RE: Summary Of Account
Attached is y ur account statement for the six month period of? iq/0 O (0,
through I ‘ 200 I , .
Utilizing the calculation formula described in BOP Procedure 5.4, your average daily balance for this
period is $ Qty; fl I .
./··· A • W_· in I - I
` A
i RE; QUEST FORM
FOR
INMATE ACCOUNT ACTIVITY STATEMENT .
Inmate Name: léeuji 5 LLVLK B SBI Number: O O kl L] 171-L_
(Last) (First) (Ml.) _
Housing Unit: S Vol Q pc J Li
` In accordance with Bureau of Prisons Procedure 5.4 entitled “In Forma Pauperis", please provide a
summary of my account transactions.
. o I " 1* f
Lsttlghg as; *\l. I aa-s£é.IlI!1
Inmate Signature Nota . ‘
L__,/
Inmate Account Activity Statement will be processed only after staff verifies your legal documents are
complete. `
. Date received by business office: X ri .
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