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

p _, J, TN _ _ . _ . · eq 00504-SLR Document 1 Filed 08/16/2007 Page 1 of 2 _
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· AO240{R.ev.10/03) i
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AL___ ___ ___ ____ UNITED STATES DISTRICT COURT
-. .,.A DISTRICT OF DELAWARE
E LDQQZ -7 QJE/Vé KQ;
y Plaintiff APPLICATION TO PROCEED
V. _ _ VVITHOUT PREPAYMENT OF
lit GJ FEES AND AFFIDAVIT
Defendant(s) -
CASE NUMBER: T —— 5 Q gi
I, /[?DFl!77 Q EM gg declare that I the (check appropriate box)
° ° PBUUOI1 Ovaut ° ° 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/petitioiu'motion.
In support of this application, I answer the following questions under penalty of perjury: _
l 1. Are you currently incarcerated? ° °No [If "No" go to Question 2)
If "YES" state the place of your incarceration /L/cF¢;uF?;§»O kéttgy ( 6'EEQZIQM L ;Z?i5?`/qi'U77$*A./
Inmate Identification Number (Required): `# fgérzg
Are you employed at thelinstitution? )L55 Do you receive any payment from the institution'? ¥§ l
l Attach a ledger sheet iiom the institution of your incarceration showing at least the past sh: months '
transactions
2. Are you currently employed? ° ° Yes `
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 l2 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 • · I
c. Pensions, annuities or life insurance payments · · Yes • • l
d. Disability or workers compensation payments • • Yes • ·‘
e. Gifts or inheritances • • Yes ·
f. Any other sources · · Yes •
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—00504-SLR Document 1 Filed 08/16/2007 Page 2 of 2 p
AO 240 Reverse [Rev. IU/03}
DEL.·\WAREj§ev. 4;’05l .
l 4. Do you have any cash or checking or savings accounts? • • Yes • ®
If "Yes" state the total amount $ ’
V 5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘ _
r • • YES •
If "Yes" describe the property and state its value. V
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.
I declare under penalty of perjury that the above infomation is true and correct.
xiavt lat, awa? gaeu Y y Y .
DATE - SIGNATURE OF` · PLICANT a
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of [ees 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—00504-SLR Document 1-2 Filed 08/16/2007 Page 1 of 1
RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
07/17/D7 11:44 `”
ST 007 / OPR SJW A __
SBI : 182595
Resident Name : WENZKE, ADAM T
Time Frame : 01/17/2007 09:02 ~ 07/17/2007 11:44
Date Time Type ST OPR Receipt # Amount Balance
01/26/2007 11:51 Add 4 gmw D62543 20.00 20.16
02/02/2007 06:51 Order 2 WLH B153306 18.14 2.02
02/09/2007 14:43 Add 10 bsp J8475 25.00 27.02
02/16/2007 10:12 Order 2 DDT B155354 24.84 2.18
02/27/2007 12:19 Add 4 gmw D64489 25.00 27.18
02/28/2007 13:15 Rec Payment 6 kjg F26226 4.00 23.18
03/02/2007 09:06 Order 2 DDT B157357 22.95 0.23
03/07/2007 12:27 Add 4 gmw D64993 200.00 200.23
03/08/2007 14:57 Rec Payment 10 bep J8729 1.75 198.48
03/09/2007 08:17 Order 2 DDT B158414 59.85 138.63
03/12/2007 08:55 Credit 3 WLH C18486 3.83 142.46
03/12/2007 14:53 Add 10 bsp J8979 25.00 167.46
03/16/2007 06:29 Order 2 DDT B159475 59.74 107.72
03/23/2007 06:29 Order 2 DDT B160466 59.97 47.75
03/30/2007 09:47 Order 2 DDT B161508 44.53 3.22
03/30/2007 11:41 Rec Payment 10 bsp J9158 1.00 2.22
04/02/2007 09:05 Credit 3 WLH C18856 4.26 6.48
04/09/2007 09:46 Payroll 10 bsp J9241 45.56 52.04
04/13/2007 05:50 Order 2 AFC B163470 51.72 0.32
04/24/2007 11:54 Add 4 CAR D67746 50.00 50.32
04/27/2007 10:45 Order 2 DDT B165508 48.56 1.76
05/09/2007 15:18 Add 10 bep J10045 45.00 46.76
05/11/2007 05:19 Order 2 DDT B167358 46.75 0.01
05/24/2007 10:51 Add 4 CAR D69483 30.00 30.01
05/25/2007 12:30 Order 2 DDT B169424 27.89 2.12
06/13/2007 13:09 Add 10 bep J10605 45.00 47.12
06/15/2007 08:11 Order 2 DDT B172234 43.52 3.60
06/20/2007 12:51 Add 4 CAR D70961 50.00 53.60
06/22/2007 09:09 Order 2 DDT B173186 50.20 3.40
07/11/2007 12:57 Add 10 bep J10847 20.00 23.40
07/12/2007 12:16 Add 4 SEA D72072 100.00 123.40
07/16/2007 05:47 Order 2 DDT 'B175872 49.33 74.07
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