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

. Case 1 :08-cv-00285-GIVIS Document 1 Filed 05/15/2008 Page 1 of 2 .
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DELAWARE Bev. 4/05
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' we/` ;j—f4\(J\l`“'“`° UNITED STATES DISTRICT COURT
if DISTRICT OF DELAWARE
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Piamttrr APPLICATION TO PROCEED
V. VVITHOUT PREPAYMENT OF
EMM OQVQ g */ /
F A?/’ M 2 9 FEES AND AFFIDAVIT
Defendant(s) __
CASE NUMBER: , O 8 ** 2 8 {2
1_ M
I, gjpg/’) p’4’/5 declare that I am the (check appropriate box)
° ° a¤t J • • other
inthe above-entitled proceeding; that in support of my request to proceed without p . . . . K- E 5 . · • ·
28 USC §l915, I declare that I am unable to pay the costs of these proceedings . d that I a TE · relief
sought in the complaint/petition/motion.
MAY l 5 2008
In support of this application, I answer the following questions under penalty of p `ury:
l. 'Are you currently incarcerated? ° °No (If "No" g to M
If "YES" state the place of your incarceration AZ C" YY 4/F//'/y DC
Inmate Identiiication Number (Required): 2 #2/Z 33Z/
Are you employed at the institution? [E0 Do you receive any payment from the institution? AA
Attach a ledger sheet Qom the institution of your incarceration showing at least the gust six mont/1s'
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
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 ;• Ng;
b. Rent payments, interest or dividends • · Yes ·>___L"
c. Pensions, annuities or life insurance payments · • Yes ·@l_>l;oi
d. Disability or workers compensation payments • • Yes •CI;Ig;
e. Gifts or inheritances • · Yes · ·@@j‘.>
f. Any other sources • • Yes CIE)
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.

Case 1 :08-cv—00285-GIVIS Document 1 Filed 05/15/2008 Page 2 of 2 .
AO 240 Reverse (Rev. 10/ 03)
DELAWARE Bev. 4/052
4. Do you have any cash or checking or savings accounts? • · Yes
If "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘
· · Ye
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.
/x/M/a;
I declare under penalty of perjury that the above information is true and correct.
Q j F4 Zwé? / Mp
DATE SIG TURE OF AP LICANT
NOTE TO 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 certiiied
statement of each account.

Case 1 :08—cv—00285-GIVIS Document 1-2 Filed 05/15/2008 Page 1 of 2
RESIDENT HISTORY REPORT E §"‘ E D P¤9€ 1 Of 2
HRYGI /;:1 1 5 gggg E:=¢
04/16/08 12:06 1*** _
ST 006 1 oPR JNM , E 1 I
` ‘*`‘ u‘Ti§"**r`*§T£:1'f:“1”’ “ · "“
SBI : 2123321 DIST?. `5 31-` IEEIIAWARE J
Resident Name : ADAMS, EDWARD E. ` I M ` M O 8 - _
Time Frame : 10/O1/2007 14:31 - 04/16/2008 12:06 2 8 5
Date Time Type ST OPR Receipt # Amount Balance
10/02/2007 08:38 Order 2 DDT B186861 20.10 33.74
10/O3/2007 09:53 Rec Payment 10 bsp J12263 2.25 31.49
10/04/2007 11:58 Add 4 SEA D76826 20.00 51.49
10/09/2007 06:21 Order 2 DDT B187815 39.11 12.38
10/09/2007 10:51 Add 4 J D76967 20.00 32.38
10/12/2007 08:02 Rec Payment 10 bsp J12317 0.50 31.88
10/12/2007 08:06 Rec Payment 10 bsp J12324 5.00 26.88
10/15/2007 11:28 Add 4 gmw D77353 5.00 31.88
10/15/2007 11:29 Add 4 gmw D77354 20.00 51.88
10/16/2007 08:40 Order 2 DDT 13188745 24.78 27.10
10/18/2007 13:56 Withdrawal 6 SJW F32595 8.00 19.10
10/22/2007 08:40 Add 4 J D77683 10.00 29.10
10/23/2007 06:48 Order 2 DDT B189673 16.35 12.75
10/23/2007 12:18 Add 4 J D77766 20.00 32.75
10/29/2007 12:04 Add 4 gmw D78069 5.00 37.75
10/29/2007 12:04 Add 4 gmw D78070 20.00 57.75
10/30/2007 07:59 Order 2 DDT B190580 30.19 27.56
10/31/2007 08:42 Credit 3 WLH C23319 4.14 31.70
10/31/2007 11:53 Rec Payment 10 bsp J12385 1.50 30.20
11/02/2007 11:10 Add 4 SEA D78351 20.00 50.20
11/06/2007 10:32 Order 2 DDT B191617 19.23 30.97
11/08/2007 11:10 Add 4 J D78682 30.00 60.97
11/09/2007 10:32 Withdrawal 6 JNM F33098 15.00 45.97
11/13/2007 06:07 Order 2 AFC B192489 24.29 21.68
11/13/2007 10:49 Add 4 J D78902 20.00 41.68
11/14/2007 08:54 credit 3 WLH C23586 2.50 44.18
11/15/2007 15:45 Rec Payment 10 bsp J12637 1.50 42.68
11/16/2007 11:22 Add 4 J D79185 20.00 62.68
11/19/2007 09:18 Add 4 J D79267 20.00 82.68
11/20/2007 07:17 Order 2 DDT B193532 27.04 55.64
11/21/2007 09:04 Credit 3 AFC C23721 1.66 57.30
11/21/2007 09:06 Credit 3 AFC C23722 0.63 57.93
11/23/2007 10:45 Add 4 gmw D79549 20.00 77.93
11/27/2007 08:26 Order 2 AFC B194378 23.62 54.31
11/27/2007 11:55 Add 4 J D79735 20.00 74.31
12/04/2007 06:26 Order 2 AFC B195304 31.38 42.93
12/07/2007 11:30 Add 4 gmw D80319 20.00 62.93
12/10/2007 08:27 Add 4 gmw D80383 10.00 72.93
12/11/2007 06:42 Order 2 DDT B196272 6.91 66.02
12/13/2007 11:44 Add 4 J D80714 20.00 86.02
12/14/2007 10:57 Withdrawal 6 SJW F33839 55.45 30.57
12/17/2007 11:27 Add 4 J D80913 20.00 50.57
12/18/2007 06:22 Order 2 AFC B197209 23.04 27.53
12/20/2007 12:16 Add 4 J D81244 50.00 77.53
12/26/2007 09:04 Order 2 DDT B198340 21.03 56.50
12/31/2007 10:50 Order 2 DDT B199118 6.73 49.77
01/03/2008 09:00 Credit 3 AFC C24741 0.68 50.45
01/08/2008 08:58 Order 2 DDT B200177 18.60 31.85
01/09/2008 15:52 Rec Payment 7 SJW G13601 1.25 30.60
01/10/2008 11:46 Rec Payment 6 JNM F34338 3.25 27.35
01/11/2008 11:34 Add 4 J D82539 50.00 77.35
O1/17/2008 11:49 Add 4 gmw D82799 20.00 97.35
01/22/2008 07:06 Order 2 DDT B201963 35.15 62.20
01/22/2008 11:12 Add 4 SEA D82984 20.00 82.20
01/22/2008 14:28 Rec Payment 7 SJW G13910 5.25 76.95
01/22/2008 15:27 Rec Payment 7 SJW G13926 0.30 76.65
01/23/2008 12:01 Add 4 gmw D83007 5.00 81.65
01/24/2008 14:06 Rec Payment 6 JNM F34966 18.45 63.20

Case 1 :08—cv—00285-GIVIS Document 1-2 Filed 05/15/2008 Page 2 of 2
RESIDENT HISTORY REPORT Page 2 ¤f 2
HR:/cn
04/16/08 12:06
SBI : 2123321
Resident Name : ADAMS, EDWARD E.
Time Frame : 10/01/2007 14:31 - 04/16/2008 12:06
Date Time Type ST OPR Receipt # Amount Balance
01/28/2008 11:54 Add 4 gmw D83324 20.00 83.20
01/29/2008 06:47 Order 2 DDT B202834 17.70 65.50
02/01/2008 10:58 Withdrawal 6 SJW F35153 30.95 34.55
02/05/2008 08:27 Order 2 AFC B203745 11.31 23.24
02/06/2008 10:23 Order 3 AFC C25583 1.30 21.94
02/06/2008 10:24 Credit 3 AFC C25585 1.02 22.96
02/08/2008 11:32 Rec Payment 7 SJW G14106 1.50 21.46
02/12/2008 06:35 Order 2 DDT B204689 21.18 0.28
02/13/2008 09:19 Credit 3 AFC C25701 0.34 0.62
02/15/2008 06:40 Order 2 DDT B205104 0.62 0.00
02/15/2008 12:37 Add 4 J D84415 50.00 50.00
02/15/2008 12:38 Add 4 J D84417 20.00 70.00
02/19/2008 11:29 Add 4 J D84586 20.00 90.00
02/21/2008 11:09 Rec Payment 7 SJW G14432 2.00 88.00
02/25/2008 05:43 Order 2 DDT B206065 36.06 51.94
02/28/2008 11:46 Add 4 J D85201 20.00 71.94
02/29/2008 09:09 Order 2 DDT B207045 21.87 50.07
02/29/2008 15:13 Rec Payment 10 bsp J12749 3.25 46.82
03/03/2008 11:45 Add 4 J D85357 20.00 66.82
03/05/2008 10:47 Rec Payment 10 bsp J12758 1.25 65.57
03/05/2008 11:11 Rec Payment 10 bsp J12771 3.25 62.32
03/06/2008 12:27 Add 4 J D85677 20.00 82.32
03/07/2008 12:11 Order 2 DDT B207970 27.95 54.37
03/10/2008 12:49 Add 4 J D85823 100.00 154.37
03/14/2008 09:26 Order 2 DDT B208952 32.72 121.65
03/17/2008 09:20 Credit 3 WLH C26416 4.25 125.90
03/17/2008 14:27 Rec Payment 7 SJW G14847 4.00 121.90
03/20/2008 14:03 Withdrawal 6 SJW F36389 9.00 112.90
03/20/2008 14:06 Withdrawal 6 SJW F36392 20.00 92.90
03/24/2008 05:31 Order 2 DDT B209915 28.90 64.00
03/24/2008 10:14 Credit 3 WLH C26682 0.68 64.68
03/26/2008 15:42 Rec Payment 10 bsp J12839 2.50 62.18
03/28/2008 11:50 Add 4 J D86933 15.00 77.18
04/04/2008 10:41 Order 2 DDT B211784 24.83 52.35
04/07/2008 13:14 Add 4 J D87553 20.00 72.35
04/10/2008 10:39 Withdrawal 6 SJW F36842 47.95 24.40
04/11/2008 09:30 Order 2 DDT B212773 22.76 1.64
04/14/2008 08:50 Credit 3 WLH C27160 2.04 3.68
04/14/2008 09:51 Add 4 gmw D87906 100.00 103.68
04/16/2008 10:48 Rec Payment 10 bsp J13297 1.50 102.18
04/16/2008 10:52 Rec Payment 10 bsp J13303 5.00 97.18
04/16/2008 11:20 Rec Payment 10 bsp J13312 2.46 94.72

Case 1:08-cv-00285-GMS

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