l fi i l t A ` at
AO240(Rev. IO/(I3) V ir M li M U _ Ay ii
DELAWARElRev. 4/05) . i "
· MEG . I E
UNITED STATES DISTRICT COURT __ _ H _ .A {
msrrucr or DELAWARE ,;.5 +5 _ Eg »A.A— r
. lg Qwest Wig mvrétiié C
Piaraarr APPLICATION TO PROCEED
V. p WITHOUT PREPAYMENT OF
Gljdccf VYQM mi $3 m`.+lx. OQR, -»»- "'iE.»i»··r:e».t£l- FEES AND AFFIDAVIT
‘ i· _ __ » Defendan (s) 4 A
M ’ /"‘·"/" '* 7*% Meier @*1**/e`$ cAsE NUMBER: 8
N`) ‘ a , — __ .
I, AC &\Â¥*â€â‚¬<·—~, V). . lz FR = t SEX ‘·}>1<. declare that I am the (check appropriate box)
l
#*5
KY ° J Petitioner/Plaintiff/Movant ° ° Other
in the above·entit1ed 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 incarcerationr y:rrr—ret\ ll Via, Hb A g/]Qg;QC.;\j.»3»A<_§ g grr
Inmate Identification Number (Required): U O
Are you employed at the institution? l&O Do you receive any payment from the institution? go
Attach a ledger sheet from the institution of your incarceration showing at least the gas: 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 answer is "NO" state the date of your last employment, the amount of your take-home
N salary or wages and pay period and the name and address of your last employer.
bm gcgj 4%*31.00 glifhcor U
3. III the past 12 twelve months have you received any money from any of the following sources?
_ a. Business, profession or other self—employment • • Yes {• • gg
b. Rent payments, interest or dividends • • Yes • • ` ‘
c. Pensions, annuities or life insurance payments • • Yes
d. Disability or workers compensation payments • • Yes • g ’
e. Giirs or inheritances • •jes_\ @{316
iX Any other sources W; es, l • • No
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. ‘
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Case 1 :08-cv—00498-GIVIS Document 1 Filed 08/08/2008 Page 2 of 2
AO 240 Reverse (Rev. l0/(B)
DELAWARE!Rev. 4£O52
4. Do you have any cash or checking or savings accounts? • • Yes {No >
lf "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
• • Yes T •No5
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.
I declare under penalty of perjury that the above infomation is true and correct.
»· / gi /7 __{\
zétsl as I /*7 //†en., q . .
` DAT X ,rti l V ~/ SIGNATURE OF PLICAN T
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 certitied 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 certitied
statement of each account.
Case 1:08—cv—00498-G|\/IS Document 1-2 Filed 08/08/2008 Page 1 of it ~¢-·
g AUG __ ZOO8
DELA WARE CORRE CTI ONAL CEN T ER\ ;W_____m 1,,.
1 Ws_M§%}?siif¢i€ ,1,’1
MEMORANDUM
` A [E5 8
TO: (En ha. , Lg; SBl#.· */co F3 g
FROM: Stacy Shane, Support Services Secretary
RE: 6 Months Account Statement
DATE: 7; 5* 3/0 F
Attached are copies of your inmate account statement for the months of
9]*,,,,1:} /,a0»i= to ("mH; so emo! _
The following indicates the average daily balances.
MONTH AVERAGE 1>A1LYBALANcE
ji A2
..L/£... .._................_
,2’L»=2 lj. L P
( new 3 w. 9 4
Average daily balances/6 months: r / V- 3 5
Attachments
CC: File /\ , ,
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Case 1 :08—cv—00498-GIVIS Document 1-2 Fnled 08/08/2008 Page 2 of 2
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Case 1:08-cv-00498-GMS
Document 1
Filed 08/08/2008
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Case 1:08-cv-00498-GMS
Document 1
Filed 08/08/2008
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Case 1:08-cv-00498-GMS
Document 1-2
Filed 08/08/2008
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Case 1:08-cv-00498-GMS
Document 1-2
Filed 08/08/2008
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