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

— Case 1 :07-cv-00527—Gl\/IS Document 1 Filed 08/30/2007 Pa e 1 of _ g
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AO 240 (Rev. 10,/03) g
DELAWARE Rev. 4 05 l F
. UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE mgrttrtgr or ortrtwsnt
rnnatrr APPLICATION TO PROCEED
. V. 5 WITHOUT PREPAYMENT OF
I 7.7r27o7ég uwwggg 25¢¢*%a}— [hl; FEES AND AFF IDAVIT
Defendant(s) $7 Up .4;;; pw;.g,t_4/
i CASE NUMBER: O T · 5 2 T
L !”/if //y /jfZ declare that I am the (check appropriate box)
°j;/(/;’;titionert’Plaintiff/l\®rant ° ° Other _ p
6/4/90/
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §1915, 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? °O4’ es ° °No (If "N0" go to Question 2)
If "YES" state the place of your incarceration
. Inmate Identification Number (Required): Q2 Q {9},2
Are you employed at the institution'?A[ 5 Do you receive any payment from the institution'?
Attach a ledger sheet from the institution of your incarceration showing at least the gas! six: :nonths'
transactions -
2. Are you currently employed? ° ° Yes °(4o
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
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 · · Yes •;?4\Io
b. Rent payments, interest or dividends · · Yes · No
c. Pensions, annuities or life insurance payments · · Yes •·/ No
d. Disability or workers compensation payments · · Yes if No
e. Gifts or inheritances • · Yes JN0
f. Any other sources · • Yes _ No
lf the answer to any ofthe 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-00527—Gl\/IS Document 1 Filed 08/30/2007 Page 2 of 2
· AO 240 Reverse (Rev. 10,/ O3)
DELAWAREliiev. 4-{U5;
4. Do you have any cash or checking or savings accounts? • • Yes 0
If "Yes" state the total amount 5
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? . _ J
· • 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 U
I indicate how much you contribute to their support, OR state NOM if applicable.
l I declare under penalty of peijury that the above information is true and correct.
, DATE _ - SIGNATURE OF APPLICANT
l
E 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
- oflicer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
1 If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.

Case 1:07-cv-00527-GIVIS Document 1-2 Filed 08/30/2007 Page 1 012
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DELAWARE CORRECTION/IL CENT ll
SUPPORT SER VICES OFFICE ate ty
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To; ( MAA [jg?} Wg; Q sent.- US"! E l
FROM: Stacy Shane, Support Services Secretary `
O T — 5 2 7 y
RE: 6 Months Account Statement
DATE.- Mggitgtgg @$1, 3661
Attached are copies of your inmate account statement for the months of
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T he following indicates the average daily balances. l
MONTH AVERAGE 1>A11;y1tALANc1:
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Average daily balances/6 months:
Attachments
Ara an

Case 1:07-cv-00527-GIVIS Document 1-2 Fnled 08/30/2007 Page 2 of 2
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Case 1:07-cv-00527-GMS

Document 1

Filed 08/30/2007

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Case 1:07-cv-00527-GMS

Document 1

Filed 08/30/2007

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Case 1:07-cv-00527-GMS

Document 1-2

Filed 08/30/2007

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Case 1:07-cv-00527-GMS

Document 1-2

Filed 08/30/2007

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