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

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I __ Case 3:03-cv-00574-CFD Document 18 Filed 04/12/2004 Page 1 of4
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O Defendant cw CASE NUMBER: 5 Z O”3“`C") $..1% C/(QD VU LSZCU,
I. *5-¤;rme.»a Pm ··)cx·\:>\r\l‘&5\l<~;I declare that l am the (check appropriate box}
ij/petitioner/plaintiff/movant |:] other i . __
in the above——entitlecl proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC. 51915 I declare that l am unable to pay the costs of these proceedings and that I am entitled ,
to the relief sought in the complaint/petition/motion. __ ` I
In support of this application, I answer the following questions under penalty of perjury;
1. Are you currently incarcerated? (gms I;] Mo (lf “r~lo" goto Part 2)
lf “Yes" state the place of your incarceration Corvlgl QM Fteczytlcm TM5 l‘%"’iJ“l"lofQ
Are y.ou employed at the institution? [ipe/fp Do you rgceive gny payment from the institution? \lJ@5 I
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Have the institution fill out the Certificate portion of this affidavit and attach a ledger sheet from the institu- i
tion(s) of your incarceration showing at least the past six months‘ transactions. I
2. Are you currently employed? mYes El No C "T; SD'®‘C’ I
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a. lf the answer is "Yes” state the amount of yourtake-home salary or wages and pay period and give the i
name and address of your employer. Q. T. iDs(3 ...§La 6 g" $’~$" 9 Wqgylqfc I
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` b. if the answer is "No" state the date of your last employment, the amount of your tal wages and pay period and the name and address of your last employer. g
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3. In the past 12 twelve months have your received any morley from any of the following sources? I
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a. Business, profession or other seif-—employment El Yes Ego I
b. Rent payments, interest or dividends I:] Yes Eye 1, .. I · A -; I
c. Pensions, annuities or life insurance payments ~» El Yes · [Bye · — ` ·
d. Disability or workers compensation payments Cl Yes Elmo
e. Gifts or lnheritances E] Yes No
f. Any other sources {fe r~m`st.L»-—— B<’es El No
lfthe answer to any ofthe above is "Yes" describe each source of mone and state the amount received and I
what you expect you will continue to receive. 45 q9cO°"-‘ Q irrrfh Flor- 'Pet-—5qgur=> l N cad S I
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1 _ Case 3:03-cv-00574-CFD Document 18 Filed 04/12/2004 Page 2 of 4 d
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- 4. Do you have any cash or checking or savings accounts? lj Yes No
I it “Yes" state the total amount. .
J 5, Do y0u OWI1 any féai estate, stocks, bonds, S€CUf' ` . OihBf fi¤&f'ICi3l Il'ISIfUI'Il6I'IlS, &UiOI'T'IObii€$ Of other i
i valuable property? ‘ E] Yes I No ‘ J
i It "Yes" describe the property and state its value. \
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6. List the persons who are dependent on you for support. state your relationship to each person and indicate f
how much you contribute to their support. ,»\),_·, M Q; - - (
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I declare under penalty of perjury that the above information is true and correct.
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-- I CERTIFICATE _ . I ‘ - ‘ ` i
I (incarcerated applicants only) `
(To be completed by the institution of incarceration)
I certify that the applicant named herein has the sum of $ , Q Q ¢ I on account to his/her i
credit at (name of institution) ( ;_g{3mgg,; cf. .. . I further certify N
that the applicant has the following securities to his/her credit: g Q é
V7 -::5 I rther a airing the past six months the applicanfs
average balance was $ `i"°°T'_'i 'lil N I`?
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DATE _ _ Sl ' TIJFIE OF AUTHORIZED OFFICER ‘
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04/ 01/ 2%%.8 $*5:08-cv-00574fSPDTMESSCSRSRIHSGT1<>RIiIed O4/12/EOM PaIge03 of 4 2.
OSB110 CONNECTICUT DEPARTMENT OF CORRECTION OTRTASTA `
T R U S T A C C O U N T S T A T E M E N T I‘lO·°·°‘9 TR I
DOC: 0000187297 Name: STERBINSKY, JAMES DOB: 01/31/1963 '
LOCATION: 115—V
Max Date:
ACCOUNT BALANCES TOta1 : 0.22 CURRENT: 0.22 HOLD: 0.00 I
- 10/07/2003 04/07/2004
SUB ACCOUNT START BALANCE END BALANCE I
SPSS-DQSA-LANCCEII I I umm-- llnn I I I 0000 25. as- nnll M ----- I I 6 . Q5-----
DEBTS AND OBLIGATIONS
TYPE PAYABLE INFO NUMBER AMOUNT OWING AMOUNT PAID I
OPOS POSTAGE 115 - 12/10/ 0.00 5.22 I
TRANSACTION DESCRIPTIONS -- SPENDABLE BALANCE SUB-ACCOUNT I
DATE TYPE TRANSACTION DESCRIPTION TRANSACTION AMT BALANCE I
I6Yd;I}E6Bé` ` "E`I§E£"`""` Etc SALIOIQISC 2II;I996ié I I ` ```` 18,7 6 I I I ` 7441 1717 I I
10/10/2003 DSP H4 /DETA DSP /FUL /Rq:1 7 10.50 54.61
@0.75 09/12/2003-09/18/2003 I
H4 /DET »
10/14/2003 CRS CRS SAL ORD #2028382 D1 ( 41.68) 12.93
10/21/2003 CEC CEC SAL ORD #2005265 7.80 20.73
_ 10/22/2003 CRS CRS SAL ORD #2045140 D1 ( 12.83) 7.90
10/22/2003 DSP H4 /0ETA DSP /FUL /Rg:1 4 3.00 10.90 ;
@0.75 09/26/2003—09/30/2003 Q
10/23/2003 DSP Inmate State Pay 112 101603 1.50 12.40 I
10/23/2003 DMR Mai1 Receipts 112 20.00 32.40 I
10/29/2003 CRS CRS SAL ORD #2056676 D1 ( 19.89) 12.51
10/29/2003 CRS CRS SAL ORD #2056954 D1 ( 4.10) 8.41
10/29/2003 CRS CRS SAL ORD #2056961 Dl ( 4.10) 4.31
10/29/2003 CEC CEC SAL ORD #2056961 4.10 8.41
11/07/2003 DSP Inmate State Pay 112 103003 10.50 18.91
11/12/2003 CRS CRS SAL ORD #2084658 D1 ( 12.96) 5.95
11/13/2003 DMR Mail Receipts 112 10.00 15.95
11/15/2003 CRS CRS SAL ORD #2090781 D1 ( 4.10) 11.85
11/21/2003 DSP Inmate State Pay 112 111303 10.50 22.35
11/24/2003 DMR Mail Receipts 112 20.00 42.35
11/26/2003 CRS CRS SAL ORD #2116609 D1 ( 42.26) 0.09 I
12/04/2003 DSP Inmate State Pay 112 112703 10.50 10.59
_ 12/10/2003 CRS CRS SAL ORD #2148609 D1 I 10.56) 0.03
12/10/2003 CEC CEC SAL ORD #2148609 0.38 0.41
12/17/2003 DED Deducti0n—OP0S—115 - 12/10/03 ( 0.41) 0.00
12/17/2003 DMR Mail Receipts 115 40.00 40.00
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O4/07/2Yfésé8*:65-cv-00574R§I?’STMEI5B¤8*Fn88I*8E`aCTI°I>*iI6d O4/12/@@4 Pa@e<>4 of 4 3
OSBIIO CONNECTICUT DEPARTMENT OF CORRECTION OTRTASTA I
I T R U S T A C C O U N T S T A T E M E N T 4`lO`O`O`9 TR I
DOC: OOOUI87297 Name: STERBINSKY, JAMES DOB: Ol/31/1963 I
LOCATION: 115-V
Max Data: g
DATE TYPE TRANSACTION DESCRIPTION TRANSACTION AMT BALANCE I
`1§`}`f@B`§ I 6667 "6é`QK§&_i`§H¥6p¤S-115 - iz»i`6)`6`3` I my " 35.14 I
12/18/2003 DSP Inmate State Pay 112 121103 6.75 41.94
12/18/2003 DSP Inmate State Pay 112 121103 2.25 44.19
12/22/2003 CRS CRS SAL ORD #2176103 D1 ( 10.55) 33.64 I
12/30/2003 CEC CEC SAL ORD #2148609 10.18 43.82 I
12/30/2003 CRS CRS SAL ORD #2193388 D1 I 31.98) 11.84
01/05/2004 CRS CRS SAL ORD #2205578 D1 ( 10.37) 1.47
03/03/2004 DMR Mai1 Receipts 115 20.00 21.47 [
03/09/2004 CRS CRS SAL ORD #2331576 D1 I 20.98) 0.49 I
O3/26/2004 DMR Mail Racaipts 115 20.00 20.49 |
I 04/05/2004 CRS CRS SAL ORD #2381468 D1 I 20,27) 0.22 `
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