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

_ Case 1:07-cv—00495-JJF Document 1 Filed 08/13/2007 Page 1 of 2 `
l ` »-\O1·ll}iRev. IO/`CBI I V .. _ _ l
V DEL.-\WAl2E(Rev. J/051 ‘ ` E
UNITED STATES DISTRICT COURT l
DISTRICT OF DELAWARE ‘ . X
Q.€C.Gr(lt ` .· » . · l `
` Plaintiff __ p APPLICATION TO PROCEED, _ r _ ‘
'C v. _ WITHOUT PREPAYMENT OF
Stax e e eee Feiss AND Arrroavrr e 5
Defendant(s)‘ I . Q
__ _ _ ,__,,,, T I ...,. .... ..r. .. » 1
I, A Q, QQFQ rs . bbc; Qi\—\·nt,`—$- declare that I am the (check appropriate box) l
M Petitioner/Plaintiff/Movant ° ° Other p ‘
in the above—entitled proceeding; that in support of my request to proceed without prepa »·· · » _•_ ees or c st A pp_p W j
28 USC §1915, I declare that I am unable to pay the costs of these proceedings and tha I am emit}? ? " `'`` U Q
sought in the complaint/petitionjmetinn. · ‘ . p . .. ’`‘> . tt..t...t i
. I. _, _ _ _ dUGl32UUl .
In support of this application, I answer the folloyig questions under penalty of pergury: · ‘ I
I. Are you currently incarcerated? ° Yes ° °No (If "`\Io" goto Q estio "`E l
` P rtr,a.at ali erntiii E
If "YES" state the place of your incarceration b•1\G*téQtt'e_, Ce V ¤ ‘ eg st. I $7* di hi'-} @4 l
Inmate Identification Number (Required): O Ca'], ‘
- Are you employed at the institution? No Do you receive any payment from the institution? .
Attach a led er s/ree! rom the institution o your irrcarceration showirtv crt lens! the ast sir mozrrfzs ’
· transactions `/ V . _ _
2. - Are you currently employed? ° ° Yes ° No I I 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 ot` your employer. nik e
V l b. lf 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 ot` your last employer. N hx -
3. In the past I2 twelve months have you received any money from any oil the following sources? e .
I a. Business, profession or other seltiemployrnent · · Yes No M. . .
b. Rent payments, interest or dividends • · Yes No
c. Pensions, annuities or life insurance payments · · Yes • · No
d. Disability or workers compensation payments · · Yes I No
e. Gifts or inheritances ‘ » ,· · Yes J`: No
t`. Any other sources . · · Yes JC No
If 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—00495-JJF Document 1 Filed 08/13/2007 Page 2 of 2
I AO 140 Reverse (Rev. IG/0.1) ·
DEL.-\vvARErRev. 4./05) |
. V l
O W 4. l Do you have any cash or checking or savings accounts? l • · Yes ` e'/No l
lf "Yes" state the total amount S D _ ` l
. a · l ' . r
S. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other ,
valuable property? [
_ • · Yes O · No ‘ _
If "Yes" describe the property and state its value. kg lk _
l l
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. Kgoqea _ .
I declare under penalty of perjury that the above infomation istrue and correct. ·
t ....·..f mxinae t . e lane., ie an ' unin l
ATE SIGNATURE OF · PLICANT ·
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
oftic er showing all receipts, expenditures, and balances during the last six months in yourinstitutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certiiied
statement of each account. ` `

::# €ase·1t074:v=00495#dJF··:·"B0cument 1-2 Filed 08/13/2007 Page 1 of 2
DELA WARE C ORRE C T I ONAL CENTER
SUPPORT SER VI CES OFFICE T
T MEMORANDUM ?
T0.- R '_ ga A LW J TA1 T B1#.· [OM; if TQ fg S
FROM· Stacy Shane, Support Services Secretary ,i_ O T -— A 9 5
RE : 6 Mon·ths Account Statement .
DATE.- Hggygggktl, Qgyl j
Attached are copies of your inmate account statement for the months of E
fg ]M;();%§\ £Q.@§\ to €,»[]Lj`§_l: sgml . I
T he fo/lowing indicates the average daily balances. R
MONTH AVEMGE 1:>A1LY1zA1;ANcE
5 ,.p_> 1 A! @0
Q; L;. Q; §)S` - QJ.
3) 12 .3; 5
·.... ‘ LJ- Q3?.
Average daily balances/6 months: { ‘ _ `
_ Attachments _
CC: `le _
4_'_ _. fd fh; ;.._
tr/tr/tf? tri/te T

Case1:07-cv-00495-JJF D0cument1-2 Filed 08/13/2007 Page20f2
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