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Case 1 :07-or-00137-JJF Document 34 Filed 06/11/2008 Page 2 of 4
Q/xo 240 [Rev. 10/os)
UNITED STATES DISTRICT COURT
liar | lm; District of 25- gmgayg.
APPLICATION TO PROCEED
Plaintiff WITHOUT PREPAYMENT OF
V FEES AND AFFIDAVIT
CASE NUMBER: O".] . 1 _ H M
Defendant J I A
I, itjrfg gl 9*1 YQ 1;/ declare that I am the (check appropriate box)
EI petitioner/plaintiff/movant |ZIother
in the above—entitled proceeding; that in support of my request to proceed without prepayment 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
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? |El'Yes I] N 0 (If “No," go to Part 2)
If "Yes," state the place of your incarceration Sei lem Carilv/1â€t;g { _o;Ygg.trQv];3l Fg 4 A { yjj [
Are you employed at the institution? Neg Do you receive any payment from the institution? Mg; . $3.513 tw/..,a.» l<
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
transactions.
2. Are you currently employed? El Yes I] No
a. If the answer is "Yes, " state the amount of your take—home salary or wages and pay period 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 salary or wages
and pay period and the name and address of your last employer.
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 [I Yes I] No
b. Rent payments, interest or dividends El Yes El No
c. Pensions, annuities or life insurance payments I] Yes I] No
d. Disability or workers compensation payments EI Yes I] No
e. Gifts or inheritances I] Yes I] No
f. Any other sources I] Yes I] No
If the answer to any of the above is "Yes," describe, on the following page, each source of money and state the
amount received and what you expect you will continue to receive.
Case 1:07-cr-00137-JJF Document 34 Filed 06/11/2008 Page 3 of 4
MRS. JOYCE S. MASSEY, CSW
Director of Social Rehabilitation
SALEM COUNTY CORRECTIONAL FACILITY
l25 Cemetery Road
Woodstown, NJ 08098
(856) 769-4300 Ext. 730
Fax.(856) 769-3578
MAY 30, 2008
TO WHOM IT MAY CONCERN:
This letter is to verify that inmate Jeffrey A. Gray, DOB 8/28/1978, has
$49.35 in his inmate account as of this date, May 30, 2008.
Any questions or concerns regarding this matter should be directed to me.
Thank you.
Sincerely,
(Mrs.) Joyce S. Massey, CSW
Director of Social Rehabilitation
Q`; 4 3 45 .$ I
Case 1:07-cifw?1 ¤ __, F Document 34 Fnled 06/11/2008 Page 4 0f 4
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Case 1:07-cr-00137-JJF
Document 34
Filed 06/11/2008
Page 1 of 4
Case 1:07-cr-00137-JJF
Document 34
Filed 06/11/2008
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Case 1:07-cr-00137-JJF
Document 34
Filed 06/11/2008
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Case 1:07-cr-00137-JJF
Document 34
Filed 06/11/2008
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