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

Case 3:00-cr-00058-AHN Document 82 Filed 10/13/2005 Page 1 of 3 B
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2 y _ , UNITED STATES DISTRICT CoUf€T\\__E D
I District of Q .QQQg;m· g-! E D 2_ 5]
UNITED ·e·rt~‘tE$ OF AMt?i2?1ZcA,
APPLICATION TQSHRQKIREHIE-OURI
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Plaintiff, WITHOUT PREPA.ItiiI•‘i`Ei2l@IRiE}i; ;
V FEES AND AFFIDAVIT
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DM~4oN 1t‘·vANt-tot? GRAHAM c.:r.v¤:t. wo: ·$=¤tcvt·r1tAu»t&
CASE NUMBER: t;\?"£t··\:tNM·- N¤:s:e0¢R·5B(AHN)
g Defendant. i
I, declare that I am the (check appropriate box) _
IE/petitioner/plaintiff/movant I] other
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in the above-entitled proceeding; that tn support of my request to proceed without prepayment of fees or costs l
under 28 USC §l915 I declare that I am unable to pay the costs ofthese proceedings and that I am entitled to the i
relief sought in the complaint/petition/motion. t
In support ofthis application, I answer the following questions under penalty of perjury: E
l . Are you currently incarcerated? ljYes El No (If"No," go to Part 2)
If "Yes," state the place of your incarceration `Fegigyggyi ('¤¤;@;¤,;;;;~,i ,L;;g,§;,‘§;;|§‘,Qg {qv-}; Q3; I
Are you employed at the institution? `ylgg Do you receive any payment from the jy/ra; ,
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months` I
transactions.
2. Are you currently employed? [Zi Yes lj No i
a. lfthe answer is "Yes," state the amount ofyour take-home salary or wages and pay period and give the i
name and address of your employer. y
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b. lfthe answer is "No," state the date of your last employment, the amount ofyour take-home salary or
wages and pay period and the name and address of your last employer. i
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3. In the past I2 twelve months have you received any money from any of the following sources?

a. Business, profession or other self—employment El Yes EStfNo
b. Rent payments, interest or dividends EI Yes l5{No i
c. Pensions, annuities or life insurance payments EI Yes - lH’No y
d. Disability or workers compensation payments El Yes l`§l’No
e. Gifts or inheritances E] Yes E/No y
f. Any other sources I] Yes [2iNo y
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Ifthe answer to any ofthe above is "Yes," describe, on the following page, each source ofmoney and state l
the amount received and what you expect you will continue to receive.

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Case 3:00-cr-00058-AHN Document 82 Filed 10/13/2005 Page 2 of 3
AO 240 Reverse {Rev. 9/90) l
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4. Do you have any cash or ci.ecking or savings accounts? Et Yes E/No l i
lf"Yes," statethe total amcunt. l
5. Do you own any real estate stocks, bonds, securities, other financial instruments, automobiles or any other °
thing ofvalue? - EI Yes El/No =
lt"‘Yes," describe the property and state its value.
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6. List the persons who are de, tendent on you for support, state your relationship to each peison and indicate
how much you contribute to their support.
I have or aix (ta) year Utd Duuqjht-er but 'I. centrrtbul-te. =oc>+h·.ng due +0 ·t-he. co.w~·en+ g
67+uqt-ton,
I declare under penalty ofperjury that the above information is true and correct.
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Date _ Signature of/\pplicant _ il i
NOTICE T0 PRISONER: A Prisoner seeking to proceed IFP shall submit an affidavit stating all assets. In
addition, a prisoner must attach a statement certified by the appropriate institutional officer showing all receipts,
_ _ expenditurcs,and balances during the last six months in yourinstitutional accounts. Ifyou have multiple accounts, ;
- ’;i"i.iii -?i>érh§1§l5ecause you have been in multiple institutions, attach one certified statement ofeach account. j
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Case 3:00-cr-00058-AHN Document 82 Filed 10/13/2005 Page 3 ot); I
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Inm te Reg #: 13787014 Current Institution: Fort Dix FCI _
` Inmate Name: GRAHAM, DAMON Housing Unit: UNIT 6
R¤v¤r¢1>¤*·== 10/02/2005 Living Qumm; S03-191L .
Report Time: 12:32:01 PM
_ l I l Commjmam Restrictions | comments I
General Il‘1i`0l‘Illt1tl01‘| - :
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Administrative Hold Indicator: No
No Power of Attorney: No
Never Waive NSF Fee: No
Max Allowed Deduction %: 100 j
PIN: 1335
FRP Participation Status: l Completed
Arrived From; PHL
l Transferred T0:
Account Creation Date: 4/26/2002 - 1
Local Account Activation Date: 3/ 17/2004 9:14:20 AM i
Sort Codes:
Last Account Update: 10/2/2005 12: 19:29 PM
Account Status: Active _
ITS Balance: $4.43
FRP Plan Inform ation ·
FRP Plan Type Expected Amount Expected Rate
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Account Balances n
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Account Balance: $90.26 ,
Pre—Release Balance: $0.00 `
Debt Encumbrance: $0.00 \
SPO Encumbrance: $0.00 1
Other Encumbrances: $0.00 i
Outstanding Negotiable Instruments: $0.00
Administrative Hold Balance: $0.00 l
Available Balance: $90.26
National 6 Months Deposits: $1,651.50
National 6 Months Withdrawals: $1,616.40 ‘
National 6 Months Avg Daily Balance: $29.40
Local Max. Balance — Prev. 30 Days: $106.11 .
Average Balance - Prev. 30 Days: $17.89
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http://140. 1 . 101. 16/umr/InmateInquiryCombined.aspx 10/2/2005
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