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

‘ Case 1:06-cv-00266-JJF Document 1 Filed O4/24/2006 Page 1 of 2
AO 240(Rev. I0/03)
DELAWARE Rev. 4lO5
UNITED STATES DISTRICT
DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
I V. 5--my {K, [L _ , WITHOUT PREPAYMENT OF
ti gis 5 { ]¤C,,£;q€·>aq,:·J at.»`? e·£;nrsr#l1·a,Q` FEES AND AF F IDAVIT
efendant(s) g
__` CASE NUMBER: M
I I Ts J` (Y- U ,
I, »,_,;;g_ H- pit L », I #`&(»~>\. "r+l *‘ declare that I am the (check appropriate box)
° ° if-Petitioner@l-aihtifflilvlovant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepa o ee st r E1
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and tha I a `
sought in the complaint/petition/motion. l
`_ * ._ Q, F
In support of this application, I answer the following questions under penalty of perjury: _I____ __ ,________,,_i,
i-;L~—~-X U.S. Llli·$'I`l·ti(`J i _`ZOi.iHI
I. Are you currently incarcerated? tres f ° °No (If "No" go to Qu stion I)lSTFtlCT OF DELAWARE
_/rr] ,_ ,· &)Ef•=;,r•r~¢?J
If"YES" state the place of your incarceration I ; tgilcu QI l‘t,,t~»l,$I;c·S·» 1 {Email;
LJ
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution? if
Attach a ledger sheet {rom the institution ot your incarceration showing at least the gast six m0nths’
transactions
2. Are you currently employed? ° ° Yes @0
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a
and give the name and address of your employer.
b. 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 I2 twelve months have you received any money from any ofthe following sources?
a. Business@fe_ssi`32>r other self-employment • • No
b. Rent payments, interest or dividends • '•_Yes
c. Pensions, annuities or life insurance payments • • Yes ( 0
d. Disability or workers compensation payments • • Yes
e. Gifts or inheritances • • Yes (·» · x _
f. Any other sources • • Yes ;No
If the answer to any of the above is "YES" describe each sour? of money and state the amount
received AND what you expect you will continue to receive. U _O;_g'- I EAI {fc _.;Lm»< [£»;;LC,j M, (
Lt-I;LL£L‘L (`L]t.¤.7J`}:"Z»rI·-·(.. ¥;:L\.}L,J£} ((f_i_{_ TI 'Cu-( JL-? `fi,{__;{_LL.:.( `{‘L_;L(»-{L if 6:

7 Case 1:06-cv-00266-JJF Document 1 Filed O4/24/2006 Page 2 of 2
AO 240 Reverse (Rev. 10/O3)
DELAWARE Rev. 4{05
4. Do you have any cash or checking or savings accounts? • • Yes •@o,
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? /.--·"“`i ~
• • Yes Qlo /
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
intyzate how much you contribute to their support, OR state NONE if applicable.
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I declare under penalty of perjury that the above information is true and correct.
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TE SIGNATURE OF AP CANT
NOTE TO 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 certified
statement of each account.

Case 1:06-cv-00266-JJF Document 1-2 Filed O4/24/2006 Page 1 of 1
lNMATE ACCOUNT STATEMENT
JOSEPH PALMER 15-Feb-06
NAME DATE ENTERED I _
‘ L tn G
123499
SBl# DATE RELEASED
DATE oeposirs Typ'; (if DISBURSE T_yp° °f BALANCE
Deposit MENT Disburs.
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 ` $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
TOTAL $0.00 $0.00 $0.00
$0.00
OPENING BALANCE
$0.00
ACCOUNT BALANCE F I L E ij
TYPE OF DISBURSMENTS
R/B room/board owed from previous visits to SWRU I. y _ J ._
MED = Visits to medical ‘ ` V I '· ·' :»‘{"°
TRANS = transportation owed from previous visits
P2 = Pay to‘s submitted thru business office U_3_ [ji§f·i{;(Ti`f_Jgji]§§-‘—
DG = Dollar General/commissary Dl§TRlCTOF DELAWARE
TRANSF Transfers to Other Institutions HO -!`¢*¤T»l···—Pw
SP. COURT Superior Court
TYPE OF DEPOSITS
M/O = money orders received outside of institution
B/R = booking and receivng
CK = checks
CASH
I/W = inmate wages
VIOLATION OF PROBATION/SCCC