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AO 240 [DELAWARE REV Tltltl)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Plaintiff , 4 APPLICATION TO PROCEED 6 ,., B Q
Defe d t s CASE NUMBER: . _. l
A·/~ “ â€â€˜â€œâ€œ p att 22 me g
I . · -’¢>·- · I... ..1. I. 2.. I.... . - t
L : Cl Um gw; Ptigclare that I am the chec S
agjhctitioner/Plaintiff/Movant I] Other the above-entitled proceeding; e--· a 'A-- =·' ga ---·I
request to proceed without prepayment of fees or costs under 28 USC §l9l 5, I declare that I am
unable to pay the costs of these proceedings and that I 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: l
l. Are you currently _incarcerated‘? ISI’{es I] No (If "No" go to Question 2)
. a ‘ we ··‘M€·l'F
- If "YES" state the place of your incarceration Igfilt LO I2- W OM E Ng CORE EU] ON JI
Are you employed at the institution? I] Yes " {No
Do you receive any payment hom the institution? I] Yes $0
Have the institution {ill out the certificate portion of this affidavit and gttach a ledger sheet Qom the
institutiontsl of your incarceration showing at least the gast SIX months' transactions. Ledger
sheets are not reguired for cases filed pursuant to 28: USC §2254.
2. - Are you currently employed? I] Yes I]/No
a. lf 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 take-home
salary or wages and pay period and the name and address of your last employer. IL! t-I·· [D -[:·····*
. _£’+¤.=r+—I-·r ~I·u "I’l;:"—»
3, In the past I2 twelve months have you received any money hom any of the following sources? tai;. ¢c.=0€.'â€
a. Business, profession or other self-employment I] Yes [260
b. Rent payments, interest or dividends I] Yes mic
c. Pensions, annuities or life insurance payments I] Yes g'/No
d. Disability or workers compensation payments I] Yes No
e. Gifts or inheritances I] Yes I]/No
f. Any other sources I]’Yes I]’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 :06-cv—00789-SLR Document 1 Filed 12/22/2006 Page 2 of 2
* ·b
4. Do you have any cash or checking or savings accounts? III Yes E4:
If "Yes" state the total amount $
` 5. Do you own any real estate, stocks, bonds, securities, other financial myénts, automobiles or
other valuable property'? EI Yes 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.
M//>~
I declare under penalty of perjury that the above information is true and correct.
Date: Signature of Applicant @@2
Case 1 ;06—cv—00789-SLR Document 1-2 Filed 12/22/2006 Page 1 of 2
1 t Date :12/16/2006
Account Activity Ledger T me ; lg , 5 O
From: 06/01/2006 To: 12/l6/2006
Tr; Batch Trx Balance
Comment Date Time flnv # Trx# Type Invoice Deposit Withdrawal Forward
ID 0018 637 6 Name WHITE , JAN A Block 8 Previous Balance 51 . 21
Sales Transaction 06/06/2006 11:18 1482324 1 11.78 39.43
PRCESSED.REC.6/2 06/06/2006 14:41 B#42419 348562 D 20.00 59.43
ZOE.SUBS.FNDRSR.6/6 06/06/2006 15:51 B#42422 348967 W -6.50 52.93
ZOE.1CE.CREAM.FNDRSR. 06/06/2006 16:34 B#42423 349337 W -5.00 47.93
Sales Transaction 06/13/2006 11:20 1#82517 1 13.16 34.77
Sales Transaction 06/20/2006 10:20 1#82720 1 21.74 13.03
RPL.1D.CHG.6/21 06/21/2006 14:22 B#42673 351191 W -4.00 9.03
rec 06/26/06 06/26/2006 14:42 B#42713 351644 D 20.00 29.03
MCP.6/22 06/27/2006 14:39 B#42733 351757 W -4.00 25.03
ZOE.FNDRSR.7/13-CHIC 06/30/2006 17:19 B#42800 352723 W -8.25 16.78
ZOE.FNDRSR.7/13.1CE. 06/30/2006 18:11 B#42801 353005 W -5.00 11.78
Sales Transaction 07/ll/2006 11:23 1#83453 I 10.37 1.41
PROCESSED.REC.7/17 07/18/2006 14:30 B#43001 354716 D 30.00 31.41
Sales Transaction 07/25/2006 10:11 1#83827 1 17.56 13.85
PROCESSED.REC.7/27 07/27/2006 16:24 8843126 356140 D 10.00 23.85
PROCESSED.REC.7/27 07/27/2006 16:24 8443126 356142 D 25.00 48.85
COMM.CRDT.7/28 07/28/2006 17:14 B#43148 356444 D 1.00 49.85
Sales Transaction 08/01/2006 15:05 1#84074 1 26.63 23.22
PRCSSED.REC.8/4 08/07/2006 14:10 B#43251 357234 D 20.00 43.22
ZOE.FNDRSR.PIZZA. 08/01/2006 17:43 B#43280 357709 W -7.00 36.22
ZOE.1CE.CRM.FNDRSR. 08/07/2006 18:17 B#43281 358031 W -2.50 33.72
Sales Transaction 08/08/2006 10:12 1#84297 I 12.85 20.87
recd 8/10 08/11/2006 10:04 B#44146 358264 D 20.00 40.87
test page 08/11/2006 10:11 B#44147 358265 W -40.87 0.00
Void Wdr # 358265 - 08/11/2006 10:11 B#44147 358267 W 40.87 40.87
rec 8/10/06 08/11/2006 11:19 B#44154 358350 D 10.00 50.87
rec 8/10/06 08/11/2006 11:19 B#44154 358352 D 10.00 60.87
rec 8/9/06 08/11/2006 11:40 B#44161 358398 D 10.00 70.87
Sales Transaction 08/15/2006 16:15 1#84481 1 42.25 28.62
Sales Transaction 08/22/2006 07:42 1#84679 1 28.58 0.04
PRCSSD.REC.8/27 08/28/2006 15:49 B#44413 360370 D 30.00 30.04
Sales Transaction 09/05/2006 10:14 1485088 I 23.62 6.42
Sales Transaction 09/12/2006 13:09 I#85321 1 5.56 0.86
PRCSD.REC.10/20.FR.1 10/20/2006 12:50 B#45392 366734 D 25.00 25.86
Sales Transaction 10/24/2006 10:15 1#86648 I 25.09 0.77
PRCSD.RCD.10/26.FR.1 10/26/2006 14:46 B#45524 367720 D 20.00 20.77
PSTD.REC.1l/2 11/02/2006 15:27 B#45658 368674 D 10.00 30.77
Sales Transaction ll/07/2006 11:35 1487084 I 29.89 0.88
PRCSD.REC.11/24 11/27/2006 14:27 B#46090 371624 D 25.00 25.88
Sales Transaction 11/28/2006 15:08 1%87660 I 25.47 0.41
PRCSD.REC.12/8.FR.12 12/11/2006 11:34 B#46351 373438 D 25.00 25.41
Sales Transaction 12/12/2006 11:39 1#88059 1 10.13 15.28
MCP.12/9 12/12/2006 12:43 B#46386 373913 W -4.00 11.28
Page : 1
' ' ° Deposits 17 For s 311.00
Withdraws 11 For 5 -46.25
Invoices 15 For $ 304 . 68
M f so 5
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BRENDA R BROWN
NOTAFIY PUBLIC, STATE OF DELAWARE
My Commission Expires Octobor 17, 2009
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