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

Case 1 :07-cv-00749-JJF Document 1 Filed 1 1/20/2007 Page 1 of 2
AO S14!} (Rev, 1.0/D3)
DELAWARE {Rev. 4/[Ei `
UNITED STATES DISTRICT COURT
P DISTRICT OF DELAWARE
. — 3 . a t i 2 I I
riannrr APPLICATION TO PROCEED
. A V. VVITHOUT PREPAYMENT OF
5o5£ie Ooo 0 i/zulizoif 6 . r “ , FEES AND AFFIDAVIT
if M z efe dan s) W — __ M
MOI wail gr ’$M@j» lh S casanuivraan; r·O T YA 9
I, mggggjl ’. 5/qt Ki. declare thatl am the (check appropriate box) _
' ' Petitioner/Plairh@/Iovant ° ° Other · · _ U
in the aboveeentitled proceeding; that in support of my request to proceed without prep yme e. _ I :
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and iii I entitled. to the relief
sought in the complaintfpetition/motion. G j
In support of this application; I answer the following (questions under penalty of perju
l. Are you currently incarcerated? °l% ° °No (If "No" go to Q estion 2)
If "YES" state the place of your incarceration ,5 St/55 1/90 ‘760/J dif'?
Inmate Identification Number (Required): J Q ¢9~
Are you employed at the institution? N/ODo you receive any payment from the institution? /
Attach o ledger sheet from the institution ot yo ur incarceration showing at least the gas! six months ' ,
transactions ‘ IA//I
2. Are you currently employed? ° ° Yes ° o

p a. If me 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. A{/
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. A//9
3. In the past 12 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 VK, •%
c. Pensions, annuities or life insurance payments · · Yes /
d. Disability or workcrs compensation payments · · Yes ·
` e. Gifts or inheritances · · Yes · N ”"
f. Any other sources · • Yes VNS
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. fj

, ·· Case 1 :07-cv-00749-JJF Document 1 Filed 1 1/20/2007 Page 2 of 2
AO 240 Reverse {Rev. `lU,’|ZB)
DELAWARE !Rev. QUE};
4. Do you have any cash or checking or savings accounts? · · Yes ·l/{ l
l If '.'Yes" state the total amount $ l U _
5. _ l Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or ther
‘ valuable property? _. ‘ ‘
` • · Yes · o
If "Yes" describe the property and state its value. /
P 6. List the persons who are dependent on you t`or support, state your relationship to each person and
U indicate how much you contribute to their support, OR state NONE if applicable.
‘¤· . - . Bi , ~_ D?#j’°i‘€’ B,a»raa»a/ Z/Mé 3/a>%»/—
C, B, . -, — QM-, xqg/any/éff p
Gr W s/ey an s

I declare under penalty of perjury that the above information is true and correct.
ri · / la ·O?
DATE SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an afiidavit
. stating all assets. In addition, a prisoner must attach a statement certiiied by the appropriateinstitutional `
ofticer showing all reccipts, expenditures, and balances du ring 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 1-2 Filed 11/20/2007 Page 1 of 2
INMATE ACCOUNT STATEMENT
GREGORY HAWKES 23-Oct-07
NAME SCCC ADMIT DATE
374876
SBl# DATE RELEASED
DATE oaposirs Typ`; gf DISBURSE WPG °f sAi.ANcE
Deposit II/IENT Disburs.
$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 $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 $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 $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 $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 room/board owed from previous visits to SVVRU
MED = Visits to medical
TRANS = transportation owed from previous visits
P2 = Pay to's submitted thru business office
DG = Dollar General/commissary g
TRANSF Transfers to Other Institutions -
SP. COURT Superior Court
TYPE OF DEPOSITS
MIO = money orders received outside of institution
B/R = booking and receivng
CK = checks
CASH
I/W = inmate wages
VIOLATION OF PROBATION/SCCC

Case 1:07-cv—00749-JJF Document 1-2 Filed 11/20/2007 "Page 2 of 2
INMATE ACCOUNT STATEMENT
RAYMOND E BLAKE 2~Nov—07
NAME SCCC ADMIT DATE
377092
SBl# DATE RELEASED
0ATE nsposrrs Typ° Qf DISBURSE Type °f sAi.ANcE
Deposit MENT Disburs.
$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 $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 $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 $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 $0.00 $0.00 $0.00
TOTAL $0.00 $0.00 $0.00
$0.00
OPENING BALANCE
$0.00 ` _.
ACCOUNT BALANCE
TYPE OF DISBURSNIENTS
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
P VIOLATION OF PROBATION/SCCC

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