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

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OCT I r` "‘ § UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
us. msiizici COURT
Disimcioi atiitmat i
lgiteiioiob Snoili liotiniit
_ riaiatirr APPLICATION TO PROCEED
V. ;__ WITHOUT PREPAYMENT OF
<5’r·:·.i· Defendan s) -
CASE NUMBER: _ if t
I, i Q,i‘\ Q i gi 5 SQ Q“i"i‘ i 2; Q +‘jE §,,\f § declare that I am the (check appropriate box)
% Petitioner/Plaintiff/Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the cornplaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? ;> If "YES" state the place of your incarceration i I ` IQ ` C ` J-
Inmate Identitlcation Number (Required): rg 3 [E E
Ar you employed at theiinstitution? M U Do you receive any payment from the institution? NIO A
A Attach a ledger sheet {fom the institution of your incarceration showing at ieast the gas: six months ’
transactions
2. Are you currently employed? ° ° Yes °><$·lo
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 we _ .
salary or wages and pay eriod and the name and address of your last employer. P\Ci§U§¢i·` l . Q ooo.
jaiarst if 3‘a€>·"“‘ ( dee:} if Semi */150 Selneol Ln Mqn; stir; 'DE _H"l3©)
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 • · No
b. Rent payments, interest or dividends · • Yes · · No
c. Pensions, annuities or life insurance payments · • Yes • · No
d. Disability or workers compensation payments · · Yes · · No
e. Gifts or inheritances • · Yes • · No
f. Any other sources Yes • · No
If the answer to any of the above is "YES" describe each source of money and state the amount
received AND what you emtpect you will continue to receive. I' RLCR Q-U CL Mbnqx p(GW\
»pqwi_§ 0tt’\C` fn (_L\"\C§5_ ( I- I`€LC`,\Cl.\lG. l)· at avi ani-in I Co:’\& i,~.>`x\\ C¤l’\‘i\ DOQ, JVB (G-C\(‘i-’~}(l. i‘i'\
Case 1 :07—cv—00635-Gl\/IS Document 1 Filed 10/15/2007 Page 2 of 3 1 - "
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AD 2dCl Reverse [Rev. ll}/D3]
DEL·\WARE$Ev. 4:052 _
l 4. Do you have any cash or checking or savings accounts? · · Yes %No
If "Yes" state the total amount $ ’
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘ .
_ · • Yes %No
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.
{Jo ME .
_ I declare under penalty of perjury that the above information is true and correct.
/0gll/aloof] g ee P
AT — 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 appropriate institutional
officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
If you have multiple accounts, perhaps hecaus you have heen in multiple institutions, attach one certitied
statement ofeach account.

Case 1:07—cv—00635-GI\/IS Document 1 Filed 10/15/2007 Page 3 013
RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
O9/28/07 11:51
ST 007 / 0102 scrw
SBI : 288386
Resident Name : OUTTEN, NICHOLAS S.
Time Frame : 04/01/2007 20:38 - 09/28/2007 11:51
Date Time Type ST DPR Receipt # Amount Balance
04/02/2007 09:30 Add 4 gmw D66424 60.00 60.38
04/10/2007 13:33 Order 2 AFC E163402 2.82 57.56
04/16/2007 06:35 Order 2 AFC B163611 49.12 8.44
04/23/2007 06:51 Order 2 WLH B164634 3.59 4.85
04/25/2007 11:23 Add 8 bef H30127 100.00 104.85
04/30/2007 06:24 Order 2 DDT E165575 29.57 75.28
05/02/2007 11:22 Rec Payment 10 bsp J9720 2.75 72.53
05/07/2007 06:42 Order 2 DDT B166525 23.81 48.72
05/14/2007 06:11 Order 2 DDT B167520 21.53 27.19 0
_ 05/17/2007 11:52 Rec Payment 10 bsp J10185 1.00 26.19
05/22/2007 12:38 Order 2 DDT B169251 20.34 5.85
05/23/2007 13:30 Credit 11 DDT K4238 2.15 8.00 _
05/29/2007 10:06 Order 2 DDT B170131 7.86 0.14
‘ 05/30/2007 12:58 Add 4 gmw D69754 100.00 100.14
06/05/2007 10:14 Order 2 DDT B171020 41.07 59.07
06/12/2007 07:10 Order 2 DDT B171773 43.98 15.09
06/19/2007 06:17 Order 2 DDT B172806 14.75 0.34
06/22/2007 11:28 Add 8 bef H31499 80.00 80.34
06/26/2007 13:28 Order 2 DDT B173898 37.47 42.87
07/03/2007 08:34 Order 2 DDT B174730 13.71 29.16
07/10/2007 06:40 Order 2 DDT B175603 28.85 0.31
07/12/2007 12:22 Add 4 SEA D72081 75.00 75.31
07/17/2007 08:47 Order 2 DDT B176672 48.47 26.84
07/23/2007 10:07 Order 2 DDT B177371 21.58 5.26
07/30/2007 08:33 Add 4 gmw D72898 50.00 55.26
07/31/2007 09:25 Order 2 DDT B178499 3.25 52.01
08/06/2007 08:54 Add 4 gmw D73311 50.00 102.01
08/07/2007 08:56 Order 2 WLH B179281 25.46 76.55
08/14/2007 11:04 Order 2 DDT 8180458 53.60 22.95
08/21/2007 11:50 Order 2 DDT B181442 21.73 1.22
08/22/2007 11:09 Add 4 gmw D74259 60.00 61.22
08/28/2007 10:15 Order 2 DDT B182348 19.73 41.49
09/04/2007 12:48 Order 2 WLH B183275 21.18 20.31
09/07/2007 11:31 Add 4 gmw D75190 70.00 90.31
09/11/2007 09:43 Order 2 DDT B184217 28.86 61.45
09/18/2007 10:15 Order 2 DDT B185236 20.22 41.23
09/25/2007 12:23 Order 2 DDT B186182 39.06 2.17

Case 1:07-cv-00635-GMS

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Case 1:07-cv-00635-GMS

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Case 1:07-cv-00635-GMS

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