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

-j;~—-——~———Gase 1:06-cv-00739-JJF Document 1 Filed 12/05/2006 Page 1 of 2
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FORM TO BE USED BY A PRISONER FILING AN I · y
. 3 ‘ APPLICATION TO PROCEED IN FORMA PAUPERIS _ i
IN A 42 UI. S. C. § 1983 CIVII. RIGHTS ACTION ` ‘ V
IN THE UNITED STA TES DISTRICT COURT · I - I
V FOR THE EASTERN DISTRICT OF PENNSYLVANIA . ·
. I. CAPTION _ ‘
, MICHIIEL CIIIXMBEIQS S I I g .
- {Enter the full name of plaintiff or . ___ _ __A_ i ' ‘
plaintiffs} . O 6 7 3 9 ;,_,
_ I/. I ` I
IWIQRNEI GENERALI CML IBIIMBERC-yl · . I II`` I I
. BES a5·2@@B ·
ETAL, A it ix
(Enter the full name of defendant or ‘ . j ._., . ..., . ...._ , , ie.,_
de fendantsl , U.S. DISTRICT COUFIT
_ . I ~ ‘ { _,__ DISTFIICT DE WARE _ _ , 1__: ;
Instructions: _ " A
The caption of this application should be identical to the caption of the complaint. A
separate application must be -completed by each plaintiff listed in_ the caption. Show your
full name in the first line of the declaration below. Pro videall information requested.
II. DECLARATION I ‘
I, {your name} IC.I"•'&·?.I CLl"h·SWV1 b€’l’\$ I . , declare that I am the plaintiff in
the above—captioned 42 U.S. C. § 1983 civil rights action, and that l am entitled to proceed
Q forma paugeris pursuant to 28 U. S. C'. § 7915 because of my inability to prepay the fu/I
fee to file this action or give security therefor. I understand that the granting of in forma
paugeris status does not waive payment of the full filing fee.
ln further support of this application, l provide the fol/owing information:
1. Do you presently have prison employment? yes I I no (XI
I 2. lf you are not employed do you have other income? I yes I I no (Xl
3, lf "yes " to either of above, state source of monthly income and amount.
Source &mOUrl1’ Q
4, lf "no, "state date- and place of last employment and amount of monthly income.
date and place 2906 SCI? /IIhi;m, Penn; ylvarti zi. amount`? 2 ?5°— UT?
5. Do you have money in a prison account? yes l I no IX} amount
6. Do you have money in a bank account? yes I I no {XI amount
7. Do you own or have an interest in valuable property such an automobile
real estate, stocks, or bonds? yes ( I no IX! `
lf "yes, " describe property value t

a Case 1:06icv-00739eJJF Document 1 Filed 12/05/2006 Page 2 of 2
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8. List the persons who depend on you for support, state their relationship to you, and ·
' how much you contribute toward their support. .—_ ·
9. State whether you have received within the past t2_months any money from any of
tlie following sources: A _ _ ‘ ‘
a. Business, profession or other form of self—employrrient yes i } no (X}
` Rent payments, interest or dividends ‘ dyes l ) no OO i i
c. Pensions, annuities ior life insurance payments » yes ( }no (X) · n
‘ d. Gifts oriinheritances yes { lno po y
e. Any other sources _ I _ yes l } no (Xl · . _ _
if the answer to any of the above is "yes," describe each source of money
g and state the amount received from each source during the past 12 months.

Ill. DECLARA TION AIVD SIGNATURE I
_ I declare under penalty of perjury that the foregoing is true and lcorrect.
c ,_w .·¢r -1 { .i __ 1 4/ YQ-gg
Q Sl u NA TUHE OF PLA lN TIFF - _ DA TE
u.
¤.>.· ts 1
1 $1. 2;+ l 1
gf r_ IV. CERTIFICATION » g
if · lgstrucsmons: I i
f` E _,i5’eqt.ii§st that an appropriate prison official provide: 1} the information below concerning
I igjur i'i§yfnate trust fund account balances; and 2) a certified copy of your inmate trust fund
accouiit statement sho wing all deposits and withdra wais for the prior six—rnonth period.
i certify that the a plicant r_La__ ed herein has the sum of 5% on account
to his credit at the f` . _ 1 1 Q ,} 4 , j' 1,; ;__A;,·,·;_ tg = institution -where he is
confined. - I-l;m.7g¤,tmgb/1 y
l further certify thatlduring the last six months the applicant's average monthly account
balance was $ ..@ ,‘ and that the average monthly deposits during the during
the last six months were S ,(f= . _
5 - t ' /1/
IG TUHE AND TITLE FAUTHORIZED OFFICIAL D E
l Page 2

Case 1:06-cv—00739-JJF Document 1-2 Filed 12/05/2006 Page 1 of 1
RESIDENT HISTORY REPORT Page 1 Of 1
HRYCI
11/27/06 12:19
ST 006 / OPR BSP
SBI : 246261
Resident Name : CHAMBERS, MICHAEL D
Time Frame : 01/13/2004 18:16 - 11/27/2006 12:19
Date Time Type ST OPR Receipt # Amount Balance
01/13/2004 18:16 Intake 1 cobra A177l 84.98 84.98
05/26/2006 12:20 Add 8 RP H21326 100.00 184.98
05/31/2006 08:35 Order 2 DDT B117468 47.17 137.81
05/31/2006 14:28 Order 9 DDT 17583 4.10 133.71
05/31/2006 14:28 Credit 9 DDT 17584 3.29 137.00
06/07/2006 -10:02 Order _ 2 DDT B118531 A 59.03 77.97
06/08/2006 14:24 Credit 2 DDT Bl187l8 1.30 79.27
06/08/2006 14:28 Order 9 DDT 17705 1.30 77.97
06/13/2006 10:48 Order 2 DDT B119524 48.40 29.57
06/14/2006 11:03 Add 4 SED D49455 25.00 54.57
06/19/2006 12:45 Add 4 SEA D49783 15.00 69.57
06/20/2006 11:31 Order 2 DDT B120501 40.18 29.39
07/04/2006 10:22 Order 2 DDT B122554 28.98 0.41
07/11/2006 07:02 Order 2 WLH B123324 0.40 0.01
07/12/2006 13:41 Credit 9 DDT 18282 0.40 0.41
07/19/2006 12:13 Add 4 SED D51210 25.00 25.41
07/24/2006 12:03 Add 4 SED D51405 250.00 275.41
07/24/2006 15:19 Rec Payment 10 hep J4582 7.25 268.16
07/25/2006 10:10 Order 2 DDT B125688 47.68 220.48
08/01/2006 14:16 Order 2 WLH B126593 59.79 160.69
08/02/2006 11:41 Add 4 SED D52050 25.00 185.69
08/09/2006 08:55 Order 2 WLH B127720 27.35 158.34
08/11/2006 13:30 Credit 11 WLH K195 27.35 185.69
08/15/2006 13:51 Order 2 DDT B128755 54.71 130.98
08/21/2006 10:01 Credit 11 DDT K295 4.90 135.88
00/24/2006 12:22 Add 4 SED D53408 20.00 155.88
08/30/2006 06:39 Order 2 WLH B130796 51.96 103.92
09/01/2006 10:47 Order 11 DDT K566 9.17 94.75
09/03/2006 13:04 Add 8 GLD H23912 80.00 174.75
09/08/2006 06:47 Order 2 WLH B131791 53.62 121.13
09/18/2006 05:53 Order 2 WLH B132846 59.37 61.76
09/18/2006 10:33 Credit 3 WLH C14744 1.22 62.98
09/25/2006 07:03 Order 2 WLH B134065 20.07 42.91
09/25/2006 11:12 Credit 3 WLH C14950 1.22 44.13
10/02/2006 09:08 Order 2 DDT B135089 36.68 7.45
10/02/2006 13:22 Order 3 WLH C15215 2.10 5.35
10/03/2006 14:20 Add 4 SEA D55765 300.00 305.35
10/04/2006 13:19 Add 4 SEA D55811 100.00 405.35
10/09/2006 06:55 Order 2 DDT B136099 51.69 353.66
10/12/2006 09:46 Withdrawal 6 kjg F22449 60.00 293.66
10/16/2006 10:28 Order 2 DDT B137217 59.10 234.56
10/18/2006 13:44 Rec Payment 10 bep J6313 4.75 229.81
10/18/2006 13:50 Rec Payment 10 bep J6320 11.50 218.31
10/20/2006 12:08 Add 4 SED D56799 20.00 238.31
10/23/2006 09:00 Order 2 DDT B138327 34.99 203.32
10/30/2006 08:24 Order 2 WLH B139331 55.53 147.79
11/01/2006 13:10 Rec Payment 10 bsp J6509 10.00 137.79
11/06/2006 10:27 Order 2 WLH B140569 37.94 99.85
11/09/2006 12:05 Rec Payment 10 bsp J6586 8.25 91.60
11/13/2006 09:58 Order 2 WLH BI41449 59.60 32.00
11/20/2006 08:47 Rec Payment 10 bsp J6968 1.25 30.75
11/20/2006 08:55 Order 2 WLH B142475 24.17 6.58