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

I 1:07-cv-00558-SLR Document 1_ Filed O9/17/2007 Page 1 of 2 ”
DELAWMl.E]Eev. {[052 . ‘ ··
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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’ , riaarrrr » APPLICATION T0 PROCEED
3 . pp V. C, r \YITHOUT PREPAYMENT OF
~· .t`J7rn /I//t’3`//Cl·j’l FEES AND AFFIDAVIT
Defendant(s) ~
CASE NUMBER: _ __
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I, si OESC Y oi G, "—-/{ declare that I am the (check appropriate box)
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• • · · D*`·"=*' • •
Pet1t1one f_/Movant Other _ _ all an up _ pl li _V“-p.-p_’· p
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in the above-entitled proceeding; that in support of my request to proceed without r= epa " ‘· ‘· i - J · ··s-za p
28 USC §l915, I declare that I am unable to pay the costs of these proceedings . d th I am entitled to the ief
sought in the cornplaintfpetitiorifmotion. Q, fl K ._
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‘ In support of this application, I answer the following questions under penalty of _ ;B|5 p 3 ;g) EgE F
1. Are you currently incarcerated? i ° ties; B ° °No {If "No" goto Question 2) BD $(`¤"""‘·G
It` "YES" state the place of your incarceration és., gt. ,. gz éra g; e _
Inmate Identification Number (Required): gi; gi CZ? 7 in ~
Are you employed at the institution? Do you receive any payment from the institution? I
Attach a ledger sheet Qom the institution of your incarceration showing at least the gas! six months '
transactions _
2. Are you currently employed? ° ° Yes I °c_Eo i_
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—horne ,_
a salary orwages and pay pegipcl anjlrthe rgme address of your last ern l0yer;»}}’;Lgy if WS/is O
vin hte? T UV ww ’ ‘*’ {/L fw €’”'”'“*f°l"* 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 • jill}
c. Pensions, annuities or life insurance payments · · Yes · " N ._ ,
d. Disability or workers compensation payments • • Yes • o
e. Gifts or inheritances · · Yes ·
f. Any other sources • · Yes • j . o J ,
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. !

Case 1:07-cv-00558-SLR Document 1 Filed O9/17/2007 Page 2 of 2 ~
AD 240 Raven: (Rev, 19/ D3) - '
DELAWARE Env. 4£'05! ` -
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 l
valuable property? - ‘
r • • YES • •N0
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.
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Ideclare hhcter penalty oxequry mat the above infomation is true and correct. L
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DATE ` / - · SIGN URE OF APPLICANT
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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 because you have been in multiple institutions, attach one certified
statement ofeach account.

Case 1:07-cv-00558-SLR Document 1-2 Filed O9/17/2007 Page 1 pf 1
RESIDENT HISTORY REPORT __ _ _ __ ` . .. ._. FQ. ? 1 Of 1 i
F7 1 ~ ` 1
07/17/07 11:21 · f
ST 007 / OPR SJW Q Q1 , Q " I
I SEP 17 ZUUI __,1 1
SBI : 159971 1
Resident Name : SELBY, JOSEPH = ...— . .» ·-r-— -- .. ,
Time Frame : 12/04/2006 14:18 - 06/30/2007 1:21 U·$·U¤3TR1GTGUUET g
_ __ DISTW T OF IAW I
Date Time Type ST OPR Receipt # Amount Balance I
1
12/04/2006 14:18 Intake 6 jmh F23660 0.00 0.00 ;
02/05/2007 12:27 Add _ 4 gmw D63149 100.00 100.00
02/06/2007 10:35 Order 2 WLH 13154209 45.82 54.18 `
02/07/2007 14:37 Rec Payment 6 kjg F25822 0.78 53.40
02/08/2007 10:45 Credit 11 AFC K2788 ` 2.55 55.95
02/13/2007 10:13 Order 2 DDT B155217 55.69 0.26
02/16/2007 10:35 Credit 11 AFC K2926 2.13 2.39
02/27/2007 08:11 Order 2 AFC 8157154 2.32 0.07
03/01/2007 11:37 Add 4 gmw D64582 20.00 20.07
03/06/2007 08:26 Order 2 DDT 8158018 19.89 0.18
03/OB/2007 13:32 Rec Payment 10 bap J8715 0.15 0.03
03/15/2007 10:58 Add 4 gmw D65495 50.00 50.03
03/16/2007 12:34 Rec Payment 6 kjg F26722 6.00 44.03 ·
03/20/2007 08:40 Order 2 DDT B160410 44.03 0.00
03/30/2007 11:55 Add 4 gmw -D6631B 30.00 30.00
· 04/04/2007 07:45 0:.-dex 2 DDT B162341 29.13 0.87 1
04/04/2007 14:24 Rec Payment 10 bap J9201 0.25 0.62
04/05/2007 12:27 Add 4 J D66694 20.00 20.62 I
04/10/2007 13:13 Order 2 AFC B163367 19.53 1.09 1
04/24/2007 09:19 Order 2 DDT 13165279 1.04 0.05
04/25/2007 11:44 Add 4 CAR D67838 15.00 15.05 -
04/26/2007 14:00 Credit 11 DDT K3736 1.04 16.09 .
04/27/2007 12:53 Rec Payment 10 bsp J9695 1.11 14.98 I
04/30/2007 12:44 Rec Payment 6 kjg F28451 4.00 10Q98 ·
05/01/2007 10:40 Order 2 DDT 13166338 10.89 0.09 I
05/03/2007 12:51 Add 4 CAR D68202 30.00 30.09 1
05/08/2007 09:40 Order 2 DDT 13167216 29.91 0.18 1
05/22/2007 12:15 Add 4 gmw D69365 20.00 20.18 I
05/25/2007 15:38 Rec Payment 10 amunc J10248 0.50 19.68 1
05/25/2007 15:39 Rec Payment 10 amunc J10249 0.10 19.58 1
05/29/2007 10:44 Order 2 DDT 13170179 19.55 0.03
06/29/2007 12:18 Add 4 grnw D71419 50.00 50.03 I
06/29/2007 13:27 Rec Payment 10 bep J10773 . 0.50 49.53 1
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Case 1:07-cv-00558-SLR

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Filed 09/17/2007

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Case 1:07-cv-00558-SLR

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Case 1:07-cv-00558-SLR

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