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

H Case 1:05-cv-00920-JJF Document 1 Filed 12/30/2005 Page 1 of 3
r O (Rev. 4/97) · UNITED STATES DISTRICT COURT
· ` __ DISTRICT OF DELAWARE
“j?*\G LGF /*5/lit ~-D}l6’l”
{S2 `APPLICATION TO PROCEED
‘“ ‘ wirnotrr PREPAYMENT or
._ V _ 1 FEES AND AFFIDAVIT
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l V)/Cl [ll Gt] tcl: N yritf) U
Def`endant(s) I
_ t · . CASE NUMBER:
JN. . » . Q?i"··@2o
I, declare that I am the (check appropriate box)
//i%._T""‘r . .
@1t10ner/Pla1nt1ff/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. a.s- E
In support ofthis application, I answer the following questions under penalty of perjuryi 5
"`~ ~ $2-.* .
l. Are you currently incarcerated? 62} No (If "No" go to Questipn 2)
"' 2 ° r_ l , {L - A ir"]: f if _- ‘ I _
If “YeS" state the place of your incarceration flirt l/l/L /)’!@;1_;» KO! f (“f/LM>u/ EU; rl /J//Irtt-J
- f,.
Are you employed at the institution? Do you receive any payment from the institution? Alb
Have rhe ],-]]SI]'[QI].Q]] fj]! edt the eertificate portion efthie gftjdavit and attach a ledger eheet frem the
iheriggtiergle) ef veur jneareeratjeh ehewing at least the paet Six merirhsj transaetiene. The ledger
sheet ie het required fer ease; fj ed pgrguargt to 2S: [JSQQ §22§4.
2. Are you currently employed? I Yes
a. If the answer is "Yes" state the amount of your take-home salary or wages and pay period and
_ give the name and address of your employer.
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. gpg tr;
£¢¤c¤.p2 ·
3. In the past twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employment Yes
b. Rent payments, interest or dividends Yes QNg··’
c. Pensions, annuities or life insurance payments Yes {Ng/"
d. nDisability or workers compensation payments Yhes e. .i?jg51fts t_Yes·* Nd
£ Any other sources Yes (JN0 ,`*
*~._/
If the answer to any ofthe above is "YES" describe each source of money and state the
amount received AND what you expect you will continue to receive.
iCj(.,(.,|,,i.,lI‘t,g_'ml s‘,»;-3,;)} {will'} lt'; rn dla-. —e~_ ;‘xi·llir-:p.;·~r..» t`r:‘;»»rm<.»ut> .

Case_1:05-cv-00920-JJF Document 1 Filed 12/30/2005 Page 2 of 3 .
4. Do you have a cash or checking or savings accounts? L I Yes - I
If"Yes" state the total amount S _—-{7c 2 _
5. ’ Do you ownany real estate, stocks, bonds, securities, other financial ins ents, automobiles or
other valuable property? Yes
If "Yes" describe the property and state its value? I
6. Listthe 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.
/N/me
I declare under penalty of perjury that the above infomation is true and correct. _
l2.[·7,6 {eq i A Z ;_
DA E SIGNATURE OF APPLICANT

. Case 1:05-cv-00920-JJF Document 1 Filed 12/30/2005 Page 3 of 3
Date :12/06/2005
· Account Activity Ledger Time :18:33
H From: 06/01/2005 T0: 12/06/2005
Trx Batch Trx Balance
Comment Date Time /Inv# Type Invoice Deposit Withdrawal Forward
ID 00343759 Name SHORT, LAKISHA Block 6 Previous Balance 5-52
REC.6/2.CK.CHAP.EARL 06/02/2005 17:45 131137567 D 10.00 15.52
Sales Transaction 06/07/2005 07:28 I1172291 I 15.39 0.13
Rsc.6/8 06/09/2005 15:24 131137873 D 20.00 20.13
Sales Transaction 06/14/2005 10:10 I1172491 I 19.25 0.88
REC.6/16.SCI.CK 06/17/2005 11:07 B1137796 D 30.00 30.88
Sales Transaction 06/21/2005 12:30 11172713 I 29.36 1.52
REC.7/7.CK.CHP.ERLE 07/08/2005 14:23 81138060 'D 10.00 11.52
Sales Transaction 07/12/2005 09:24 I1173312 I 10.39 1.13
REC.7/11 07/13/2005 11:48 81138110 D 10.00 11.13
Sales Transaction 07/19/2005 09:42 I1173511 I 10.27 0.86
Mcp.7/21 07/22/2005 15:54 131138251 w -4.00 -3.14
PROCESS]-ED 8/2 08/03/2005 14:12 B1138425 D 20.00 16.86
PROCESSED/REC.8/4.CK 08/05/2005 14:49 B1138463 D 10.00 26.86
EXTRA.ZOE.ICECREA1V1.F 08/05/2005 15:09 B1138464 W -2.50 24.36
Sales Transaction 08/09/2005 09:40 11174113 I 19.42 4.94
PROCESSED.REC.VR.8/1 08/19/2005 16:47 B1138634 D 25.00 29.94
rec 8/23/05 08/24/2005 15:29 131138878 D 20.00 49.94
rec 8/23/05 08/24/2005 15:29 B1138678 D 20.00 69.94
Sales Transaction 08/26/2005 10:48 101174666 I 22.47 47.47
Sales Transaction 09/06/2005 11:22 111:74893 I 34.13 13.34
Mcp.9/7 09/08/2005 12:55 131138839 w -4.00 9.34
9/9/05 09/09/2005 13:54 B1138884 D 10.00 19.34
Sales Transaction 09/13/2005 09:41 I1175101 I 13.31 6.03
P/T.RED.CROSS.9/14 09/14/2005 15:53 B1138951 W -3.00 3.03
PROCESSED.REC.VR.9/2 09/23/2005 12:43 B#39lO2 D 25.00 28.03
Sales Transaction 09/27/2005 10:38 I1175500 I 27.12 0.91
PROCESSED.REC.VR.CK. 10/07/2005 12:12 131139267 D 10.00 10.91
Sales Transaction 10/11/2005 10:19 11175897 I 8.28 2.63
PROCESSED.REC.10/20 10/21/2005 14:32 B1139455 D 10.00 12.63
Sales Transaction 10/25/2005 09:35 I1176316 I 11.28 1.35
PROCESSED.REC.VR.10/ 10/28/2005 11:37 B1139536 D 25.00 26.35
Sales Transaction 11/08/2005 11:17 I1176738 I 25.64 0.71
PROCESSED.REC.VR.11/ 11/10/2005 16:42 B#3972l D 10.00 10.71
Sales Transaction 11/29/2005 09:32 11177222 I 9.25 1.46
Deposits 16 For $ 265.00
Withdraws 4 For $ -13.50
Invoices 14 For $ 255.56

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