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

3 Z A ‘ Case 1:06-cv-00025-JJF Document 1 Filed 01/13/2006 Page 1 of 4 , O I O O
_ * Aozan (R.etr.1D/U3) “ . ` l I
. .7 t DELAWARI-Iggey. 4[Q) · , ‘ . ’ - . `
AL UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
B {T'?
time tl. Colon
T rnimtrr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
C M3 FEES AND AEEIDAVIT
Defendant(s) O 6 ··· O 2 5 .
__, I CASE NUMBER:
I, \B UOQ Q · CO i© M declare that I am the (check appropriate box)
° ° Petitione ovant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, 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:
1. Are you currently incarcerated? ® ° °No "N0" go to Question 2)
r If"YES" state the place of your incarceration kgwgfgi tp EOLLL %; C.Off€£,fl[;i')Qi If\'t3rl‘|"iLL—llO/)
. · I"
Inmate Identification Number (Required): IH; 7 6 D7
Are you employed at the institution? Tiff 5 Do you receive any payment from the institution? ` U ( `
Attach a led er sheet orn the institution o our incarceration showin at [eas the ast si? si Q i
transactions A """`“‘“l
2. Are you currently employed? ° ° Yes @ ‘| 3 2006 f
a. Ifthe answer is "YES" state the amount of your take-home salary or wa es -· ,,_______i
and give the name and address of your employer. EMWQQE;
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 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment · · No
b. Rent payments, interest or dividends • • es
c. Pensions, annuities or life insurance payments • • Yes • • No
d. Disability or workers compensation payments • • Yes @
c. Gifts or inheritances · • Yes
f. Any other sources · • Yes -
Ifthe 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.

i Case 1 :06-cv-00025-JJF Document 1 Filed O1/13/2006 Page 2 of 4
AO 240 Reverse (Rev. 10/ U3] ·
DELAWARE mgm ` .
h 4. Do you have any cash or checking or savings accounts? • • Yes ®
If "Yes" state the total amount $ 1
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘
‘ ‘ Ys @
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.
idols ti;
I declare under penalty of perjury that the above information is true and correct.
7 —· 5 —OG sam , &»/ .
DATE, - SIGNATURE OF 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 certified
statement of each account.

Case 1 :06-cv-00025-JJF Document 1 Filed O1/13/2006 Page 3 of 4
RESIDENT HISTORY REPORT Page 1 of 2
HRYCI
D1/10/D6 14:25
ST DO7 / OPR KJG
SBI : 277657
Resident Name : COLON, JOSE A
Time Frame : 01/13/2004 18:17 - 01/10/2006 14:25
Date Time Type ST OPR Receipt # Amount Balance
01/13/2004 18:17 Intake 1 cobra A2147 0.96 0.96
01/16/2004 17:15 Add 7 SZG G192 15.84 16.80
01/19/2004 12:39 Order 2 IM B425 10.21 6.59
01/22/2004 08:27 Add 8 RP H151 25.00 31.59
01/26/2004 14:09 Order 2 IM B1367 26.00 5.59
02/03/2004 06:36 Order 2 IM B2284 5.39 0.20
02/03/2004 12:17 Add 4 RWW D975 25.00 25.20
02/09/2004 10:20 Order 2 DDT B3235 22.23 2.97
02/13/2004 15:14 Add 7 SZG G573 16.56 19.53
02/17/2004 09:56 Order 2 IM B4448 1.95 17.58
02/24/2004 08:50 Order 2 IM B5459 16.76 0.82
03/10/2004 12:06 Add 4 RWW D30B9 50.00 50.82
03/16/2004 08:36 Order _ 2 DDT B8597 48.55 2.27
03/18/2004 07:44 Add 7 KTS G900 7.68 9.95
03/23/2004 12:19 Order 2 DDT B9798 5.65 4.30
04/13/2004 06:09 Order 2 DDT E12597 1.95 2.35
04/27/2004 07:08 Order 2 DDT B14507 1.95 0.40
05/07/2004 13:00 Add 4 jxs D6175 20.00 20.40
05/11/2004 06:11 Order 2 DDT B16307 20.14 0.26
06/07/2004 14:27 Add 4 CK D7674 50.00 50.26
06/15/2004 14:05 Order 2 DDT B20871 41.39 8.87
06/18/2004 11:58 Add 7 KTS G2261 2.52 11.39
06/22/2004 10:58 Order 2 DDT B21701 8.59 2.80
07/13/2004 05:59 Order 2 WLH B24416 1.95 0.85
07/18/2004 11:24 Add 7 KTS G2607 9.80 10.65
07/20/2004 06:17 Order 2 DDT B25394 10.07 0.58
08/10/2004 12:15 Add 4 CK D10962 40.00 40.58
08/17/2004 07:51 Order 2 DDT E28977 40.46 0.12
08/24/2004 09:40 Add 4 CK D11561 30.00 30.12
09/01/2004 06:24 Order 2 IM B30789 29.34 0.78
09/01/2004 11:40 Add 7 LIH G3108 9.80 10.58
09/15/2004 07:49 Add 7 KTS G3256 7.84 18.42
09/20/2004 13:09 Add 4 SED D12940 20.00 38.42
09/21/2004 06:39 Order 2 IM E33398 17.69 20.73
09/21/2004 13:53 Add 4 SED D13047 25.00 45.73
09/28/2004 06:43 Order 2 DDT E34369 36.63 9.10
10/12/2004 05:57 Order 2 DDT B36084 8.62 0.48
VYIOT/07/2005 21:09 Add 5 CMJ E5976 0.01 0.49
V 01/18/2005 06:18 Order 2 DDT B48335 0.46 0.03
01/19/2005 11:19 Credit 9 IM I1942 0.46 0.49
01/25/2005 07:29 Order 2 DDT B49189 0.39 0.10
07/06/2005 12:41 Add 4 SEA D28318 20.00 20.10
07/11/2005 07:19 Order 2 DDT E70495 19.55 0.55
09/16/2005 06:33 Add 7 KTS G6865 11.90 12.45
10/04/2005 10:52 Order 2 WLH B82351 9.70 2.75
10/06/2005 11:27 Add 4 SEA D33800 10.00 12.75
10/12/2005 05:47 Order 2 DDT B83407 12.64 0.11
10/14/2005 11:55 Add 4 CK D34302 »40.00 40.11
10/18/2005 08:32 Add 7 KTS G7909 13.50 53.61
10/18/2005 09:04 Order 2 DDT B84406 39.72 13.89
10/21/2005 12:05 Add 4 SEA D34705 10.00 23.89
10/25/2005 08:45 Order 2 DDT B85403 21.53 2.36
10/28/2005 12:46 Add 4 SEA D35149 15.00 17.36
10/31/2005 13:52 Order 2 DDT B86290 13.50 3.86
11/03/2005 14:51 Rec Payment 10 LIH J344 0.75 3.11
11/21/2005 13:42 Order 2 DDT B89127 3.07 0.04
11/22/2005 07:08 Add 7 KTS G8343 13.50 13.54
11/25/2005 11:25 Add 4 SED D36907 20.00 33.54

Case 1 :06-cv—00025-JJF Document 1 Filed O1/13/2006 Page 4 of 4
RESIDENT HISTORY REPORT Page 2 Of 2
I-IRYCI
01/10/06 14:25
ST 007 / OPR KJG
SBI : 277657
Resident Name : COLON, JOSE A
Time Frame : 01/13/2004 18:17 - 01/10/2006 14:25
Date Time Type ST OPR Receipt # Amount Balance
11/29/2005 05:50 Order 2 DDT B90187 8.15 25.35
12/05/2005 12:58 Order 2 DDT B91048 24.89 0.46
12/18/2005 18:17 Add 7 KTS GB692 13 .50 13.96
12/23/2005 13:44 Add 4 CK D38B96 20.00 33.96
12/26/2005 09:48 Order 2 DDT B940B2 12.60 21.36
01/03/2006 11:46 Order 2 DDT B94979 19.72 1.64