_ AOTAU (Rev. 10/03)
_) DELAWARE (Rev. 4/05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
THOMAS A . WILCOX
Plaintiftl APPLICATION TO PROCEED
v. WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
STATE OF DELAWARE ET AL.
A E BER:
Defendant(s) p C S NUM 0 ? _ 7 5 9
I, declare that I am the (check appropriate box) A
. E Petitioner/Plairitiff/Movant lj 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 comp 1aint/petition/ motion. A
In support of this _application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? E Yes [JN0 (If "No" go to Question 2)
If "YES " state the place of your incarceration DELAWARE CORRECTIONAL SMYRNA DELAWARE
19977 ·
Inmate Identiiication Number (Required): 449725
Are you employed at the institution? No Do you receive any payment from the institution? No
_ Attack a ledger sheet (orm the institution of your incarceration showing. at least the past six months ’
transactions l
2. Are you currently employed? I:] Yes E No
a. Ifthe 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. Ifthe 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. OVER 5 YEARS
AGO
3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other selfernployment E Yes E No
b. Rent payments, interest or dividends A [Z] Yes E No `
c. Pensions, annuities or life insurance payments [;\ Yes E No
d. Disability or workers compensation payments [I Yes E No
e. Gifts or inheritances . I;] Yes E No
£ Any other sources I:] Yes E No
If the answer to any of the above is "YES" describe each source of money and state the amount receive what you
expect you will continue to receive. F I D
***1%
. . us olsmlct COURT
mcromt or l1¥lZ;W£lil:
· t ,C,,_,,,,,,,_,,,,,Qase 1 :07-cv—00739—Gl\/IS Document 1 Filed 1 1/19/2007 Page 2 of 2
° DELAWARE (Rev. 4/05)
4. D0 you have any cash or checking or saving accounts? [I Yes E No )
If “Yes" state the total amount $ -
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other 1
valuable property? [I Yes E No
If "Yes" describe the property and state its value. i
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. _
NONE. _-
- I declare under penalty of perjury that the above information is true and correct. i
l
, , l
tl ( ca; [ gre] gt . -g/.t&@d2.» Q1 l
DATE SIGNATURE OF APPLICAN `
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 certified by the appropriate institutional
ofhcer showing all receipts, expenditures, and balances during the last six months in your institutional accotmts. If
you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each accoimt.
ab Case 1:07-cv-00739-G|\/IS Document 1-2 Filed 11/19/2007 Page 1 012
A or-rss
DELA WARE C ORRE C T I ONAL CENTER
SUPPORT SER VI CES OFFICE
MEMORANDUM A
ro; WMM gl Cdtrfdnz gf sE1#.- are 7015
FROM: /}7e,re.e/J —c s I/A L1./I.)
RE: 6 Months Account Statement
DATE.- {og .25; v7 l
Attached are copies of your inmate account statement for the months of
Apgl taco; to cgfgfmtbgég 6200 Z.
The following indicates the average daily balances. J Q. mEV_{·
MONTH AVERAGE DAILYBALANCE E ga Q , m-
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Average daily balances/6 months: fl - 0'D
Attachments ·
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(1)
Case 1:07-cv-00739-GMS
Document 1
Filed 11/19/2007
Page 1 of 2
Case 1:07-cv-00739-GMS
Document 1
Filed 11/19/2007
Page 2 of 2
Case 1:07-cv-00739-GMS
Document 1-2
Filed 11/19/2007
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Case 1:07-cv-00739-GMS
Document 1-2
Filed 11/19/2007
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