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

Case 1:07—cv—00634-Gl\/IS Document 1 Filed 10/15/2007 Page 1 of 3 _ ’
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AD 240 (Rev. ID/D3] l e { »i.. 1... ie)
_ DELAWARE v. •L D5 ` -—·—····
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=> UNITED STATES DISTRICT COURT GCI I EGG?
DISTRICT OF DELAWARE
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..-#"” Di5IRlCI OF DEL/WJARE
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_ Pinstirr APPLICATION TO PROCEED
v, WVITHOUT PREPAYMENT OF
5 i Te D i»/— 6 »C I ness Ann AFFIDAVIT
Defendant(s . q q U
CASE NUMBER: i F
I, 5 E .f Z 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 §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? °X°fes ° °No (If "No" go to Question 2)
If "YES" state the place of your incarceration ‘ g ‘ Y ‘ C I
Inmate Identification Number (Required); -T-I i S
Are you employed at thelinstitution? N D Do you receive any payment from the institution? Q i
I Attach a ledger sheet {fom the institution of your incarceration showing at least the past six months ’
transactions A
2. Are you currently employed? ° ° Yes ` °`XlNo
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 tralce-hicgnec
l d ' d d th d ddr f 1 t 1 . #{*0 ,
M¤i~·>§%·‘€’{ °t5”rig?S t£i&’iZ·%°“2¤$`~ ¤»~i°`6“‘“iz“§`. a»u?§i?t ".E·t`i.i$? ° P —rifOMaa. an l. Mo?
3. In the past 12 twelve months have you received any money from any of the following sources? §qlar(`)/
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 X 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 expect you will continue to receive. QAA {Q" _
MOI $&)(`€L IQ jnftvt JC (`°[·C#l*G~`*i(L "\V\\f M0 (`CL .

Case 1 :07—cv—00634-Gl\/IS Document 1 Filed 10/15/2007 Page 2 of 3 _ ~ "
` AO 240 Reverse (Rev. 10/D3)
DELAWARElEev. 4[GSZ .
i 4. Do you have any cash or checking or savings accounts? • • Yes XNo
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 XNo
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.
lei aref.
I declare under penalty of perjury that the above information is true and correct.
Z O g I l Q OG"? . cz
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 certitled by the appropriate institutional
of ticer 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—00634-GI\/IS Document 1 Filed 10/15/2007 Page 3 of 3
I!
` RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
O9/28/07 11.:54
ST 007 / OPR SJW
SEI : 1794989
Resident Name : DIAZ, JOSE
Time Frame : 04/01/2007 10:13 — 09/28/2007 11:51
Date Time Type ST OPR Receipt # Amount Balance
04/30/2007 10:13 Intake 4 gmw D68073 25800 25.00
05/03/2007 14:11 Add 4 CAR D68308 15.00 40.00
- 05/08/2007 10:53 Order 2 DDT B167295 39.04 0.96
05/14/2007 10:06 Add 4 gmw D688B4 100,00 100.96
05/22/2007 12:38 Order 2 DDT B169237 53.18 47.78
05/23/2007 13 :33 Credit 11 DDT 1:4240 1.70 49.48
05/29/2007 10:05 Order 2 DDT B170121 44.36 5.12
06/06/2007 09:58 Order 11 DDT K4470 3.52 1.60
06/25/2007 09:05 Add 4 CAR D71112 30.00 31.60
06/26/2007 13:28 Order 2 DDT B173888 31.56 0.04 *
- 07/02/2007 11:58 Add 4 CAR D71500 50.00 50.04
07/03/2007 08:34 Order 2 DDT B174720 49.22 0.82
07/23/2007 10:07 Order 2 DDT B177358 0.78 0.04 :
_ 07/27/2007 10:48 Credit 2 DDT B177853 0.78 0.82
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Case 1:07-cv-00634-GMS

Document 1

Filed 10/15/2007

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Case 1:07-cv-00634-GMS

Document 1

Filed 10/15/2007

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Case 1:07-cv-00634-GMS

Document 1

Filed 10/15/2007

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