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

fj - 1 :07—cv—00539-GI\/IS Document 1 Filed 09/07/2007 Page 1 of 2 _ Y
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—* DELAWARE gev. qui · ` ‘ _
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
L arr; /"\ $&g—i—¤/i St?.
y rtstnttrr APPLICATION TO PROCZED
V. WITHOUT PREPAYMENT OF
€f¤t·l—Q o-li Di?. . [ !l· X- C -12 FEES ANI) AFFIDAVIT
Defendant(s) -
CASE NUMBER: O 7 - 5 3 9
I, i·— Ot ·"f` g ff § Sr?. 5 'l`O/1 $5* K declare that I am the (check appropriate box)
.. A Pc-lr wi » ac ef`
°\/( » ° ° Other Q,)-N gx/)Q&/Cr L E
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, Ideclare 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: _ ,3
1. Are you currently incarcerated? ° °No {lf "No" go to Question 2)
. in -»·--, “"
If "YES" state the Place of your incarceration H ` Q ' \j ‘ C ' J. "U 2-t?”*rr
I ITD @*·`
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Inmate Identification Number (Required); S /5 ,_¤
l :1: E;5.
Are you employed at the institution? MO Do you receive any payment from the institution? Ap A
Attach a ledger sheet Qom the institution of your incarceration showing at least the past six monmaf Ti
transactions
2, Are you currently employed? A
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. lf the answer is "NO" state the date of your last employment, the amount of your take—home OGULC * {O —2mB`
. salary or wages and pay period and the name and address of your last employer. il I2 m hoof .
Pct rr-i~ +·r"`r’\ C .
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 ® • • No
b. Rent payments, interest or dividends · · es _
c. Pensions, annuities or life insurance payments • • Yes •
d. Disability or workers compensation payments · · Yes
. e. Gifts or inheritances • · Yes N
f. Any other sources • • 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.

r Case 1:07-cv-00539-Gl\/IS Document 1 Filed 09/07/2007 Page 2 of 2 _ _. _ "
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DELAWARE {gev. 4/U5} V
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V PW ·""°r’\ ‘?€’¤é$ V"€-.- 2,0 ·5·c» 2;-S Dcllcsri Qx/icy 2_ WeQ,bL5
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i 4. Do you have any cash or checking or savings accounts? • · Yes
If "Yes" state the total amount $
S. Do you own any real estate, stocks, bonds, securities, other financial i.nsl.ruments, automobiles or other
valuable property? ‘ .
. · · Ye QB
‘ 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.
Log/gin
_ I declare under penalty of perjury that the above infomation is true and correct.
°Y··5· O'?
DATE SIGNATURE OF APPLICAN
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 of each account.

~ Case 1:07-cv-OO539—GI\/IS Document 1-2 Filed O9/07/2007 Page 1 0f 1
RESIDENT HISTORY REPORT Page 1 Of 1
HRYCI
08/31/07 09:18
ST 007 / OPR SJW
SBI : 298313
Resident Name : SEXTON, LARRY M
Time Frame : 01/01/2007 15:17 - 08/31/2007 09:18 O 7 _ 5 3 9
Date Time Type ST DPR Receipt # Amount Balance
01/03/2007 12:01 Add 5 CTN E19204 0.01 0.01
01/08/2007 12:08 Add 4 CAR D61527 25.00 25.01
01/22/2007 09:29 Order 2 DDT B151667 24.42 0.59
01/23/2007 12:42 Add 4 SED D62334 20.00 20.59
01/26/2007 11:09 Rec Payment 10 rpate J8088 4.00 16.59
01/29/2007 11:47 Order 2 WLH B152798 15.04 1.55
_ 02/01/2007 12:29 Add 4 grnw D62930 40.00 41.55
R 02/02/2007 12:50 Credit 3 WLH C17854 15.04 56.59
. 02/05/2007 09:38 Order 2 WLH B153746 15.77 40.82
02/12/2007 10:05 Order 2 DDT B154711 11.25 29.57
• 02/19/2007 11:22 Order 2 DDT B155905 9.18 20.39 .
02/26/2007 09:41 Order 2 AFC 8156819 5.87 14.52 {
` 03/05/2007 09:55 Order 2 DDT 8157827 6.86 7.66
03/08/2007 12:11 Add 4 gmw D65098 20.00 27.66
03/12/2007 09:21 Order 2 WLH B158757 7.69 19.97 °
03/12/2007 09:53 Add 4 J D65222 50.00 69.97 \,
03/19/2007 10:20 Order 2 DDT B159906 17.26 52.71
03/20/2007 11:16 Credit 3 WLH C18642 2.35 55.06
03/26/2007 09:41 Order 2 DDT B160911 13.33 41.73
04/02/2007 09:44 Order 2 DDT B161863 13.53 28.20
04/09/2007 11:33 Order 2 AFC B162832 14.00 14.20
04/10/2007 10:40 Add 4 CAR D66948 48.00 62.20
04/11/2007 12:30 Add 4 gmw D67053 40.00 102.20
04/13/2007 15:45 Rec Payment 10 bsp J9598 1.75 100.45
04/16/2007 09:54 Order 2 AFC B163895 21.78 78.67
O4/19/2007 12:05 Rec Payment 10 bsp J9651 0.75 77.92
04/23/2007 11:14 Order 2 DDT B164953 15.78 62.14
04/25/2007 12:21 Add 4 CAR D67879 30.00 92.14
04/30/2007 09:34 Order 2 DDT B165824 15.44 76.70
05/07/2007 09:38 Order 2 DDT B166831 14.17 62.53
05/14/2007 09:00 Order 2 DDT B167729 10.32 52.21
05/15/2007 10:39 Credit 3 WLH C19557 1.41 53.62
05/15/2007 10:40 Order 3 WLH C19558 4.80 48.82
05/17/2007 08:57 Add 6 kjg F29235 3.41 52.23
05/21/2007 09:10 Order 2 WLH 13168784 10.67 41.56
05/25/2007 11:59 Add 4 gmw D69555 25.00 66.56
05/28/2007 09:22 Order 2 DDT B169638 16.81 49.75
05/29/2007 11:22 Credit 3 WLH C20067 1.66 51.41
06/05/2007 05:39 Order 2 DDT B170645 18.93 32.48
06/11/2007 09:40 Order 2 DDT B171495 11.20 21.28
06/11/2007 11:57 Add 4 gmw D70447 20.00 41.28
06/18/2007 10:48 Order 2 DDT B172594 16.31 24.97
06/25/2007 10:39 Order 2 DDT 13173572 13.99 10.98
06/25/2007 12:14 Add 4 CAR D71200 20.00 30.98
07/03/2007 08:34 Order 2 DDT 13174732 9.90 21.08
07/10/2007 06:40 Order 2 DDT B175604 11.23 9.85
07/17/2007 08:47 Order 2 DDT E176673 9.76 0.09
07/23/2007 08:17 Add 4 gmw D72504 20.00 20.09
07/23/2007 10:07 Order 2 DDT B177373 9.89 10.20
07/25/2007 11:21 Add 4 gmw D72699 20.00 30.20
07/31/2007 09:25 Order 2 DDT B178500 13.16 17.04
08/01/2007 13:28 Credit 11 WLH K4937 3.26 20.30
08/06/2007 11:34 Add 4 gmw D73352 25.00 45.30
08/07/2007 08:56 Order 2 WLH B179283 14.41 30.89 `
08/14/2007 11:04 Order 2 DDT B180460 15.74 15.15 _
08/20/2007 11:50 Add 4 SEA D74160 25.00 40.15
- 08/21/2007 11:50 Order 2 DDT E181443 14.85 25.30 __
08/28/2007 10:15 Order 2 DDT B182350 15.19 10.11

Case 1:07-cv-00539-GMS

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Filed 09/07/2007

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Case 1:07-cv-00539-GMS

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Case 1:07-cv-00539-GMS

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Filed 09/07/2007

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