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

Case 1 :06-cv-00798-SLB Document 1 Filed 12/29/2006 Page 1 of 2
AO 240 (Rev. l0/03)
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Winfred Brown Sr
Plaintiff, APPLICATION TO PROCEED
v. WITHOUT PREPAYNIENT OF
FEES AND AFFIDAVIT
Warden Thomas Carroll
Defendant(s) CASE NUMBER:030500 1486
I,Winfred Brown Sr, declare that I am the (check appropriate box) OL; Q C`] `K
E Petitioner/Plaintiff/Movant I;] Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under 28 US
§l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in tl
complaintfpetitionl motion.
In support of this application, I answer the following questions under penalty ofperjiuy: F L L E U
l. Are you currently incarcerated? E Yes E No (If "No" go to Q tio15 2) H
If "YES" state the place of your incarceration Delaware Correctional Center ,l I"
Ll . __ _ 3 .’
Inmate Identification Number (Required)· 00019174 U`§¥.`3i;?E TCT CGUTE-M "
‘ waettwtaae _____l_
Are you employed at the institution? Yes Do you receive any payment from the institution? Yes
Attack a ledger sheet {orm the institution of your incarceration showing . at least the past six months ’
transactions
2. Are you currently employed? E Yes I;] No
a. If the answer is "YES" state the amount of your tal and give the name and address of your employer. $58.00 per /1.-rpg;)-j
b. If the answer is "NO" state the date of your last employment, the amount of your tal salary or wages and pay period and the name and address of your last employer.
3. In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employment I;] Yes IX] No
b. Rent payments, interest or dividends I;] Yes IE No
c. Pensions, annuities or life insurance payments I:] Yes E No
d. Disability or workers compensation payments I] Yes B No
e. Gifts or inheritances lj Yes IZ 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 wh:
you expect you will continue to receive.

Case 1:06-cv-00798-SLR Document 1 Filed 12/29/2006 Page 2 of 2
AO 240 (Rev. l0/U3)
DELAWARE (Rev. 4/05)
4. D0 you have any cash or checking or saving accounts? [II Yes E No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other valuable
property? E Yes E 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 if applicable.
None.
I declare under penalty of perjury that the above information is true and correct.
M {
DATE ‘ SIGNATURE OF APPLICANT
NOTE T0 PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an aftidavit stating a
assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional ofiicer showing a
receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multipf
accounts, perhaps because you have been in multiple institutions, attach one certified statement of each accotmt.

Case 1:06-cv—00798-SLR Document 1-2 Filed 12/29/2006 Page 1 of 1
DELA WARE C ORRE C T I ONAL CENTER
SUPPORT SER VI CES OFFICE
MEM ORAND UM .
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F ROM: Stacy Shane, Support Services Secretary V _ __ _
RE: 6 Months Account Statement - · ( ,;
DA we ii __
Attached are copies ofyour inmate account statementfor the months of
Thefollowing indicates the average daily balances.
MONTH AVERAGE DAILYBALANCE
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Average daily balances/6 months.· 3 Cl
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