AO 240 (Rev. 10/03)
DEIAWARE 4{G5}
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Q / E
WM la xl J om v\
Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
W » " if 1 . t" ~ ta _ FEESANDAFFIDAVIT
efendant( y R
CASE NUMBER: ` “ r
I, mv l ·. ;/Q 5,,*5 mica Vx declare that I am the (check appropriate box)
’ ’ Petitioner/Plaintiff7Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed wi • ut p p ~ P • ts · er
28 USC §l9l5, I declare that I a.n1 unable to pay the costs of these proceed' ; . p- that I am entitled to V e r ief
sought in the complaint/petition/motion. AUG 1 _"
In support of this application, I answer the following questions under penalty • pexj l V
1- AIC YOU currently incarcerated? • No (If ·•NO·· go to Question 2)
If "YES" state the place of your incarceration ioctl 57<>r?’ [ com 1/ 235107 Qom #1-Engl V4" C~¢e,,g·1e§g·g;] 05 W7? 7
Inmate Identification Number (Requircd):_ YK (QL: 7,
A Are you employed at the institution? Us Do you receive any payment hom the institution? L
Attach a ledger sheet Qom the institution ot your incarceration showgng at least the gast six months '
. transactions .
2. · Are you currently employed? ° ° Yes
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. If the answeris "NO" state the date of your last employment, the amount of your take-home U
salary or wages and pay period and the name and address of your last employer.
3*0* $$7~¥¢`;—éT).l.n/V/·~ Cept i\a¤tlt`ta\§rt.._,\ Dmlntl low mast AW, wuts ll K mftill
3. In thepast 12 twel months have you received any money iiom any of the following sources?
a. Business, profession or other self-employment · • Yes . g•
b. Rent payments, interest or dividends · • Yes • • /_:~
. c. Pensions, annuities or life insurance payments • · Yes d.€.No.>
d. Disability or workers compensation payments • Z No
e. Gifts or inheritances • • es
£ Any other sources • • Yes ;l&;Q>
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,
OIR/\0‘\iL7 V`/N/lLvy,5;'Chm{0Lln { .OU/n_(,/ ML.MULl\
. I . . Case 1 :08-cv-00516-SLR Document 1 Filed 08/13/2008 Page 2 of 2
AO 240 Reverse naw. mm;
DELAWARE!Ev.
4. Do you have any cash or checking or savings accounts? • • No
If "Yes" state the total amount $ {lll) .""
5., Do you own any real estate, stocks, bonds, sectuities, other financial instruments, automobiles or other
valuable property? r
• • No
If "Yes" describe the property and state its value.
%`¥»_,_V,¥’·(, JA/A { l'[(}‘ LM L("U\l"\f\·•/\~L\
Fwd Wlv\¥n·rw\ is $17003 -» 65 ii Ml optri/~i»¢,·\o\t
lair/•‘\.)u j (;Vl1zW&· l’Mv'l{m’§‘· ·w»/Jifl, VAWJUK (§4l
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 NOAH if applicable.
A i` @1, ih 7/000,/ I/h,ymH‘ L7 gy WV g£‘r»
7
I declare under penalty ofpeijury that tl1e above information is true and correct.
as 3.. xr- @8 y l_ at / _ ,,_/,Am_.,..
DATE ’ . SIGNA OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepaymentof fees shall submit an afiidavit
stating all assets. In addition, a prisoner must attach a statement certified bythe appropriate institutional
officer showing-all receipts, expenditures, and balances during the last s-ix 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.
[ash méwh M0; g/7/dy [ t
Case 1:08-cv—00516-SLR Document 1-2 Filed 08/13/2008 Page 1 of 2
INMATE ACCOUNT STATEMENT
PAMELA BERGMANN 22-Jul-08
NAME SCCC ADMIT DATE
175662
DATE RELEASED
DATE osposirs Ty'°° gf DISBURSE TYp° °f BAi.ANcE
Deposit MENT Disburs.
$0.00 $0.00 $0.00
7/23/2008 $40.00 INTAKE $0.00 $0.00 $40.00
7/30/2008 $0.00 $1.50 Mail Supplies $38.50 $38.50
7/31/2008 $0.00 $2.87 Mail Supplies $35.83 $35.83
7/31/2008 $0.00 $6.00 Medical $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
$0.00 $0.00 $29.83 $29.83
TOTAL $40.00 $10.17 $29.83
$0.00
OPENING BALANCE
$29.83
ACCOUNT BALANCE
TYPE OF DISBURSMENTS
R/B room/board owed from previous visits to SWRU
MED = Visits to medical
TRANS = transportation owed from previous visits
P2 = Pay to's submitted thru business office
DG = Dollar General/commissary
TRANSF Transfers to Other Institutions
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
Case 1:08-cv—00516-SLB Document 1-2 Filed 08/13/2008 Page 2 of 2
REQ QUEST FORM
FOR
INMATE ACCOUNT ACTIVITY STATEMENT
Inmate Name SBI Number:
(Last) (First) (Ml.)
Housing Unit: V C`)? QC; Q
In accordance with Bureau of Prisons Procedure 5.4 entitled "ln Forma Pauperis", please provide a
mary 0 ' account traitsactioV \ \ g
I 1 M c>—» ¤~·’* _• $•_ EMA \
ate ignatu Notary ' /
Inmate Account Activity Statement will be processed only after staff verifies your legal documents are
complete.
Date received by business office: k E .
INMATE ACCOUNT STA EMENT
l
TO: Inmate Name V- \{\
{La , _ (First) (MII.)
SBI Number: i
Housing Unit
FR: Inmate Account Technician
DA: Cb
RE: Summary Of Account
Attached ° your account statement for the six month period of
through
Utilizing the calculation formula described in BOP Procedure 5.4, your average daily balance for this
period is $ ·
Atta m it _
I o ary 5-*HA
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