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

Z _ . Case 1 :06-cv-00773-SLR Document 1 Filed 12/19/2006 Page 1 of 2 1 .
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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_ Piamurr APPLICATION T0 PROCEED
_ V. VVITHOUT PREPAYIVIENT OF
__ FEES AND AFgIDzgVI?T-{ 3
Defendant(s) ‘:°I"°‘E‘r`\"°"E= 6 .
`I CASE NUMBER:
Ld ; 3 ggggg Q; Q , A , Q3; 55 g declare that I am the (check appropriate box)
° ° Petitione ovant ° ° Other i
in the above-entitled proceeding; that in support of my request to proceed without pre e l ? l
28 USC §19l5, I declare that l am unable to pay the costs of these proceedings and hat I ai ` -l . L — ‘
sought in the complaint/petition/motion.
DEC ‘tQ2tlllt3t
‘ In support of this application, I answer the fo ing questions under penalty of peij : __.,.. E
1— AP3 YOU CUHGHIIY incarcerated? * •N0 (If¤•NOu ga to ;.i__;mr _!_ F _ _ t
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. If "YES" state the place of your incarC€I3ll0¤ ~..§*<—°*k.<;»—¤
Inmate Identitication Number (Required): E 2 323 y
Are you employed at the institution? _m}_ Do you receive any payment from the institution? " l-
- Attach a ledger sheet Qorn the institution opf your incarceration showing at least the past sb: months ' i_
transactions _ I
2. Are you currently employed? ° °Yes ( ° No`) .i
a. Ifthe answer is "YES" state the amount of your take-home salary or wages and pay period a I
and give the name and address of your employer.
bi Ifthe 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.
3. , In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other selfernployment • • Yes · N I =
b. Rent payments, interest or dividends I • • Yes
c. Pensions, annuities or life insurance payments • · Yes . . o
d. Disability or workers compensation payments · · Yes *· · "‘ ` .
e. Gifts or inheritances · • Yes
f. Any other sources • • Yes I
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.

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AO 24G Reverse (Rev. 1U/03) .
DELAWARE Eev. · ` .
l 4. Do you have any cash or checking or savings accounts? • • Yes 6:%; B
If "Yes" state the total amount S '
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
, valuable property? ` _p__g _ ,
· · Yes
` 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 A
indicate how much you contribute to their support, OR state NONE if applicable. _
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\\§ came;. A _
J _ I declare under penalty ofpeijmy that the above information is true and correct.
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DATE. - SIGNATU it APPLICANT .
NOTE T0 PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
- stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
officer 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 certilied
statement of each account. ‘

_ Case 1:06-cv-00773-SLR Document 1-2 Filed 12/19/2006 Page 1 of 1
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" RESQDENT HISTORY REPORT Page 1 ef 1
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HRYCI
11/17/06 09:34
ST 007 / OPR JMH
SBI : 557338
Resident Name : JONES, EM ANUEL
Time Frame : 05/27/2006 22:52 - 11/17/2006 09:34
Date Time Type ST OPR Receipt # Amount Balance
05/27/2006 22:52 Add 5 1mw E15269 11.10 · 11.25
06/07/2006 10:24 Order 2 DDT B118583 10.89 0.36
07/21/2006 11:50 Add 4 SED D51356 150.00 150.36
07/26/2006 08:47 Order 2 DDT B125854 59.16 91.20
08/02/2006 11:02 Order 2 WLH B126817 58.20 33.00
08/07/2006 12:45 Credit “ "LH B127185 13.58 46.58
08/07/2006 12:46 Order `LH B1271B6 18.97 27.61
08/16/2006 08:57 Order DDT 8128959 1.41 26.20
08/16/2006 13:41 Credit 2 DDT B12B971 1.41 27.61
08/23/2006 08:32 Rec Payment 10 bsp J524B 2-75 24.86
me/20/2006 08:10 Rec Payment 10 bep J525B 3.15 21.71
os/21/2006 08:56 Order 2 WLH B130894 1.88 19.83
09/04/2006 11:01 Order 2 WLH B131199 13.82 6.01
09/11/2006 06:58 Order 2 WLH B132079 5.44 0.57
10/02/2006 06:42 Order 2 DDT 8134996 0.46 0.11