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

T — _ ‘ Case 1 :06-cv-00019-SLR Document 1 Fj|ed.01/10/2006 Pagé'°i°hf 3 ,_ 5a3I if 54/3%)
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DELAWARE {Bev. 4/052 ‘ . ‘
UNITED STATES DISTRICT COURT
Q I Gl N AL DISTRICT OF DELAWARE
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Piamnrr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
\,de~t—A..»_.,. Ra@aa\ LO .\; t 5 at 5 FEES AND AFFIDAVIT
Defendant(s) {J - 1 Q
` CASE NUMBER:
I, S C, b ... "p~o\O c rx S cz R declare that I am the (check appropriate box)
° \’/ Petitioner/Plaintiff/Movant ° ° 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:
l. Are you currently incarcerated? ® ° °No (If "No" go to Question 2)
If "YES" state the place of your incarceration §§ E Q ~"( . L · X. »
Inmate Identification Number (Required): 5 [ gr
Are you employed at the institution? YU O Do you receive any payment frqm.the_institi1tio1;?__, __ _ V
Attach a ledger sheet Qom the institution of your incarceration showing atgleast ge giz.stJs1Zx.`in‘ont`h,‘si ’ _._ i
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2. Are you currently employed? ° ° Yes J ‘i*"·l i l O 2005 1
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zi l-~...,,.. __ ?
a. If the answer is "YES" state the amount of your take-home salary or wages and pay pefiodia} J T ’ E
and give the name and address of your employer. ~ .. {il ii-ViB]...;"Ti_*ef_-¥il;{—Q"`;_*·_”___ _ _, }
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.
3. , In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment • • Yes • • No
b. Rent payments, interest or dividends · • Yes • N
c. Pensions, annuities or life insurance payments • · Yes @
d. Disability or workers compensation payments • • Yes @
e. Gifts or inheritances • • Yes
f. Any other sources • • Yes @
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.

t ~ _ , Case 1:06-cv-00019-SLR Document 1 Filed Ot/10/2006 Page 2 of 3 V
AO240Reverse(Rev.10/03) it
DELAWARE BEV. 4105 l A. "~
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I 4. Do you have any cash or checking or savings accounts? @ • •No
If "Yes" state the total amount $ I OO -
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? i _
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.
A.) O rx L
I declare under penalty of perjury that the above information is true and correct.
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-00019-SLR Document 1 Filed 01/10/2006 Page 3 of 3
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RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
12/22/05 09:48
ST 006 / OPR KJG
SE1 : 541362
Resident Name : ROBERTSON, JOHN H
Time Frame : 01/10/2005 12:46 — 12/22/2005 09:48
Date Time Type ST OPR Receipt # Amount Balance
01/10/2005 13:23 Intake 8 RP H8994 50.00 50.00
01/21/2005 14:08 Close 6 kjg F8789 50.00 0.00
09/O1/2005 12:46 Reopen 5 NSM E10290 11.00 11.00
09/12/2005 06:42 Order 2 DDT B79004 10.94 0.06
09/12/2005 13:11 Add 4 SEA D32141 50.00 50.06
09/19/2005 06:52 Order 2 DDT B79996 48.88 1.18
O9/26/2005 06:26 Order 2 DDT B80983 1.18 0.00
09/26/2005 11:57 Add 4 SEA D33012 50.00 50.00
10/03/2005 06:30 Order 2 DDT B81930 47.91 2.09
10/07/2005 11:38 Add 4 CK D33903 200.00 202.09
10/10/2005 06:53 Order 2 DDT B82884 59.66 142.43
10/14/2005 13:54 ReC Payment 7 KTS G7770 2.25 140.18
10/14/2005 14:11 Rec Payment 7 KTS G7775 3.00 137.18
10/17/2005 06:35 Order 2 DDT B83873 45.96 91.22
10/24/2005 08:22 Order 2 DDT B85020 36.21 55.01
10/24/2005 13:25 Add 8 RP H15833 50.00 105.01
10/31/2005 06:34 Order 2 DDT B85837 45.28 59.73
11/04/2005 10:49 Credit 9 WLH 15285 45.28 105.01
11/04/2005 10:58 Order 2 WLH E86755 45.28 59.73
11/07/2005 06:28 Order 2 WLH B86808 25.14 34.59
11/07/2005 09:52 Order 9 WLH 15293 17.97 16.62
11/07/2005 14:26 Add 8 RP H16198 50.00 66.62
11/10/2005 14:34 Rec Payment 7 kjg G8270 2.90 63.72
11/14/2005 06:18 Order 2 DDT B87735 56.32 7.40
11/15/2005 13:55 Order 9 WLH 15397 2.50 4.90
11/18/2005 06:37 Order 2 DDT B88765 4.84 0.06
11/21/2005 11:41 Add 4 SED D36529 70.00 70.06
11/24/2005 10:51 Credit 9 WLH 15498 4.84 74.90
11/25/2005 10:32 Order 2 DDT E89798 52.70 22.20
12/05/2005 05:52 Order 2 DDT B90791 20.10 2.10
12/08/2005 11:43 Add 4 SEA D37714 65.00 67.10
12/09/2005 08:07 Order 2 DDT B91672 58.43 8.67
12/15/2005 13:20 Add 8 RP H17133 75.00 83.67
12/16/2005 07:20 Order 2 DDT B92717 59.40 24.27
12/19/2005 10:41 Credit 3 WLH C9964 1.02 25.29