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

Case 1 :08-cv-00265-SLR Document 14 Filed 08/13/2008 Page 1 of 2
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UNITED STATES DISTRICT COURT i L (
DISTRICT OF DELAWARE Em AUG I3 pgs 3; I, {
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Piaimitr APPLICATION TO PROCEED
I . · WITHOUT PREPAYMENT OF
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Us Yx Defendant(S) Q.,) . Ox., .
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I, I Q declare that I am the (check appropriate box)
° ° Petitioner ovant ° ° 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.
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 incarceration , “ ‘ · I - Q;,tJ~V;\/
Inmate Identitication Number (Required): {
Are you employed at the institution? Yi Do you receive any payment from the institution'? cig
Attach a led er sheet rom the institution o vow incarceration showing at least the ast sir MOIIZILS`1
transactions
2. Are you currently employed? ° ° No
a. If the answer is "YES" state the amount of your glrehome salary or wages and ay e 'od a t
and give the name and address of§ur employe O 5 Oc l~/\»{A Ig-4
- . .. " . .
\\ $§\ ‘&Dt1. x..Esv~c»x/kitjtltx DIE. \°I*’\'\‘\ J
b. If the answer is "NO" state the date of your las employment, the amount of your take-home
salary or wages and pay period and the name and address ot`your last employer. N/ A
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
b. Rent payments, interest or dividends · · Yes · I
ci Pensions, annuities or life insurance payments · • Yes · @18
d. Disability or workers compensation payments · · Yes · •
e. Gifts orinheritances • • Yes ·
f Any other sources {gs · · No
If the answer to any of the above is "YES" describe each source of money pad state the_amount •’
A received AND what you expect you will continue to receive. Yu qt. h'D~,W__ _) Qi }~· PAL {A Op
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Case 1:08-cv-00265-SLR Document 14 Filed 08/13/2008 Page 2 of 2
AO 240 Reverse (Rev 10/O3)
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4. D0 you have any cash or checking or savings accounts? • · @9 • •No
If "Yes" state the total amount $ ES; arg S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
• • Yes · QQ
/
If "Yes" describe the property and state its value. {
My {P,
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.
A7 A
I declare under penalty of perjury that the above information is true and correct.
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E SIG ATU OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an aftidavit
stating all assets. In addition, a prisoner must attach a statement certified 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-00265-SLR Document 14-2 Filed 08/13/2008 Page 1 0f 1
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DELAWARE CORRECTIONAL CENTER
SUPPORT SER VICES OFFICE
MEMORANDUM
TO.- Q 1 Q gg: gg Q ésé SBI#.· / ¢/e/a rc,
FROM: Stacy Shane, Support Services Secretary
RE: 6 Months Account Statement
DATE: 8/,g@e
h Attached are copies of your inmate account statement for the months of
rCg,_¢,; fg Sov! to 3/ Qcgf .
T he following indicates the average daily balances.
MONTH AVERAGE oA1L1/EALA1vcE
/5; A; A 32.,55;
X}/MAKE gcc. /03 5-% ii
gp M A gr. 27 E
I:T§H2:: CQPM/Je ee
LAF *’/$(52 `——= V
Average daily balances/6 months: Wx 74- /5
Attachments X
File · /&_)/LLL:/if
(7 s/» 1/ 5

Case 1:08-cv-00265-SLR

Document 14

Filed 08/13/2008

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Case 1:08-cv-00265-SLR

Document 14

Filed 08/13/2008

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Case 1:08-cv-00265-SLR

Document 14-2

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