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

' = Case 1 :07-cv—00749-JJF Document 8 Filed 12/18/2007 Page 1 of 2
no 240 ma-. twin) ` ‘ ‘?» T? ``8`1 [i `‘1·‘‘ ·· `*` *
DELAWARE (Rev. 4 05 _ A .1 _v__
UNITED STATES DISTRICT COUR _ SEC 1 8 mg?
DISTRICT OF DELAWARE
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I Plaintiff 3. ‘-·""‘·'$ ,°A‘3,`Qt;r,,.f§“§`r,iieAPPLICATION T0 PROCEED gp Smnnpw
5»·55£*;:¢' Cetnniwoiie · °"?»¢•·‘¤fI'$
cU__(_w`w`_m\ Lfjwy, 5 WW U, Mime! ;,.,5my,_ WITHOUT PREPAYMENT OF
og E; gm gg 5 yy 5 megan Qemgj g2._>g;,r—i`a FEES AND AFFIDAVIT _
Defendant(s) _
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i I, E.- .i Great- s · ‘· declare thatl am the (check appropriate box)
( Petitioner/Plaintiff/Movanptii ° ° Other I Q
in the above-entitled proceeding; that in support of my request to proceed withoutprepayment of fees or costs under
28 USC §19l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
j sought in th@omp1ain§‘petition/motion. i
3 In support of this application, I answer the-followin questions under penalty of perjury: I C l M I y an- C l I I- I I
J 1. Are you currently incarcerated? {/% ° °No (If "No" go to Question 2)
y If "YES" state the place of your incarceration 5 V G -
. y Inmate Identification Number (Required): `7 Lg E l l
Are you employed at the institution? [gl D Do you receive any payment from the institution? g
‘ Attach o ledger sheet from the institution of your incarceration showing ot feast the post six months ’
¤ trortsoctiorzs . .
; _ a. If the answer is "YES" state the amount of your tal i . and give the name and address of your employer. [Q J A
· b. If the answer is "NO" state the date of your last employment, the amount of your talce—home
, salary or wages and pay period and the name and address of your last employer. M A
i 3. In the past 12 twelve months have you received any money from any of the following sources? —<
i a. Business, profession or other self-employment • • Yes ·
; b. Rent payments, interest or dividends · · Yes •
j c. Pensions, annuities or life insurance payments · · Yes •
{ cl. Disability or workers compensation payments · · Yes • o
* e. Gifts or inheritances ` · · Yes · _
; ti Any other sources · · Yes ·' o
. lf the answer to any of the above is "YES" describe each source of money and state the amount
Y received AND what you expect you will continue to receive. M j Pt

Case 1 :07-cv—00749-JJF Document 8 Filed 12/18/2007 Page 2 of 2
AO 240 Reverse {Rev. 10/G3)

4. Do you have any cash or checking or savings accounts? - · · Yes W6 I
If` "Yes" state the total amount S · ( I
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other U
valuable property? l ’ - ·
‘ • · Yes · o
lf "Yes" describe the property and state its value. I U
- 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.
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I declare under penalty of perjury that the above information is true and correct.
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DATE SIGNATURE OF APPLICANT `
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 certified by the appropriateinstitutional
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 certified
statement of each account. _

Case 1:07-cv-00749-JJF Document 8-2 Filed 12/18/2007 Page 1 of 1
. ` jg ` ‘ INIVIATE ACCOUNT STATEMENT
ANTHONY GARNETT 26-Nov-07 ‘
NAME SCCC ADMIT DATE
376811 I
DATE RELEASED
I
0ATE DEPOSITS Typg gf DISBURSE T_yp° °f sA1.ANcs
Deposit MENT Disburs. I
$0.00 $0.00 $0.00 I
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 '
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 I
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 I
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00 I
$0.00 $0.00 $0.00 $0.00 I
$0.00 $0.00 $0.00 $0.00 I
$0.00 $0.00 $0.00 $0.00 `
$0.00 $0.00 $0.00 $0.00 I
$0.00 $0.00 $0.00 $0.00 .
$0.00 $0.00 $0.00 $0.00 I
$0.00 $0.00 $0.00 $0.00 I
$0.00 $0.00 $0.00 $0.00 I
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
TOTAL $0.00 $0.00 $0.00
$0.00
OPENING BALANCE
$0.00 ‘
ACCOUNT BALANCE
TYPE OF DISBURSIVIENTS _
R/B r00m/b0ard ewed frem previeus visits te SVI/RU
MED = Visits te medicai
TRANS = transpertatien evved tr0rn previeus visits
P2 = Pay t0's submitted thru business eifice
DG = Deitar Generai/cemrnissary
TRANSF Transfers tc Other Institutions
SP. COURT Supener Ceurt
TYPE OF DEPOSITS
M/O = meney erders received eutside 0f institutien
B/R = t>00I CK = checks
CASH I
I/W = inmate vvages
VIOLATION OF PROBATION/SCCC

Case 1:07-cv-00749-JJF

Document 8

Filed 12/18/2007

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Case 1:07-cv-00749-JJF

Document 8

Filed 12/18/2007

Page 2 of 2

Case 1:07-cv-00749-JJF

Document 8-2

Filed 12/18/2007

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