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

, Case 1:07-cv—00023-SLR Document 1 Filed O1/11/2007 Page 1 of 2 T
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, r DELAWARE {Rev. QQ} ‘ , ` ` ‘ ‘ ~
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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, Plaintiff ‘ APPLICATION TO PROCEED
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— -. — c i. -» FEES ANI) AFFIDAVIT
Defendant(s)
" CASENUMBER: ,. O '{ Q, ie 2 3 —-
I, ·=· . ~ LD declare that I am the (check appropriate box)
° l?Petitioner/Plaintifffl~/iovarit ° ° Other l
q in the above-entitled proceeding; that in support of my request to proceed without prep j i " ````
28 USC §l915, I declare that I am unable to pay the costs of these proceedings and rg;-rtl r». L
sought in the complaint/petition/motion. U
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‘ In support of this application, I answer the following questions under penalty of perj :
l. Are you currently incarcerated? ° °No (If "No" go to r.... siiklii` . , . M
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, It"'YES" state the place of your incarceration gcigggd lz . _ }:cc;g% £i;QKlériL;nQ·ix`·ir.¤A‘€?
Inmate Identitication Number (Required): i
I Are you employed at the institution? gg; Do you receive any payment from the institution? Q ';i 2 l-
- Attach a ledger sheet Qom the institution of your incarceration showin at least the past six months '
transactions p -
2. Are you currently employed? ° ° Yes — -
a. If the answer is "YES" state the amount of your tal 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 take-home
salary or wages and pay perio‘d_an he name and address of your last employer. FC bfacp QDE )2c>©€¤
l lC\lv»<<£s\" no EU Pip; anew °lw‘tl’* 3. . In digest 12 tvlzeliie mohths naive yoii received any money from any of the t`ollo*§ing`2h' (?%Om3%€'L IQ
a. Business, profession or other seliemployrnent · · Yes · · No
b. Rent payments, interestor dividends ‘ • · Yes · · No
c. Pensions, annuities or life insurance payments • • Yes · · No
d. Disability or workers compensation payments ° ’ Yes • * No
e, Gifts or inheritances ° ° Yes, · • No
f. Any other sources ' ' No `
If the answer to any of the above is "Y`ES" describe each source of money and state the amount
received AND what you expect you will continue to receivei__|i°·;\€ MLA %_,DL,_v2_ v\_.\L—>,\€®
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_ Case 1 :07-cv—00023-SLR Document 1 Filed O1/11/2007 Page 2 of 2
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l 4. Do you have any cash or checking or savings accounts? ° ‘ Yes
If "Yes" state the total amount $ ·
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
g valuable property? i r ._
· · Yes
I It` "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 N ONE if applicable.
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_ I declare under penalty of perjury that the above information is tmc and correct.
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DATEA · SIGNATURE OF APPLICANT .
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
A stating all assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional
ofticer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.
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Case 1 :07—cv—00023-SLR Document 1-2 Filed 01/11/2007 Page 1 of 1
RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
12/22/06 11:00 ...,, 0 »~ y
ST007/OPRJMH 7hm23—~
SBI : 231393
Resident Name : BROWN, ROBERT D
Time Frame : 02/16/2006 11:46 - 12/22/2006 11:00
Date Time Type ST OPR Receipt # Amount Balance
02/16/2006 11:46 Close 6 kjg F16896 90.18 0.00
08/23/2006 14:29 Add 4 SED D53371 25.00 25.00
00/29/2006 05:46 Order 2 WLH 13130238 24.75 0.25
09/08/2006 11:52 Add 4 SED D54216 20.00 20.25
O9/ll/2006 06:41 Order 2 WLH 13132017 20.12 0.13
09/14/2006 13:59 Rec Payment 10 bsp J5715 0.10 0.03
10/24/2006 13:21 Add 4 SED D57025 10.00 10.03
10/25/2006` 13:53 Rec: Payment 10 bsp J6448 2.00 8.03
10/27/2006 15:25 Rec Payment 10 bsp .36488 1.35 6.68
10/30/2006 06:32 Order 2 WLH B139143 6.27 0.41
12/15/2006 13:57 Add 8 bsf I-[26670 22.00 22.41
1-2/18/2006 06:34 Order 2 WLH B146376 22.21 0.20
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