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

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l X'; Case 1 :05-cv-0001 3-G MS Document 7 Filed 03/18/2005 l l ' age { A
(M. we UNITED STATES DISTRICT COUR 1 g I
DISTRICT OF DELAWARE s s _ . i t g j
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’?é;»/~»·¢ » ‘ S __ I __ A. o DF
rumen APPLICA ` __ ‘‘=`’ ; ’ "' 0 PROCEEI;
” v. WITHOUT RAXMENT O
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Defendant(s)
V g p l CASE NUMBER: 6*;,.. 0 /3 __._ /775
I, m$ /P//Ein --a /g` declare that I am the (check appropriate box)
{ I’etitionerfPlaintifflMovant U Other `
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
tmder28 USC §1915, I dedarethat I am unable to pay the costs of these proceedings and that I am entitled to the
relief sought in the complaintlpetitionlmotion. ` '
In support of this application, I answer the fo estions under penalty of perjury:
1. Are you currently incarcerated? Yes EI No (If "No" go to Question 2)
If "YES" state the place of your incarceration -»[· { - in K 0 GOX - Aw D? HM}
Are you employed at the ' · · ` · _· _· 1. . lg: 3 I receive any payment from the institution? C}
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2. Are you currently employed? E Yes U No
I a. If the answer is "YES" state the amount of your take-home salary or wages and pay period and
give the name and address of your employer. ,
b. If the answer is "NO" state the date oi' your iam: employment, the amount of your take-home
salary or wages and pay period and yj name and address of our last loyer.
. » was _ * _. _ W _ J o r _ ,_=— r _ _, ‘ /3 a cov
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. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment u Yes `¤’IIlo·
b. Rent ayments, interest or dividends u Yes ¤"l%/.
c. dns, annuities or life insurance payments ¤ Yes cfg;
d. Disability or workers compensation payments ¤ Yes U’No
e. Gifts or inheritances D Yes u/No
f. Any other sources D Yes E46}
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.

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Case 1 :05—cv§0O1 3-G MS Document 7 Fnled 03/ 1 8/2005 Page 2 of 3 A
_ 4. Do you have cash or checking or savings accounts? ¤Yes I1`!/No ·
E If "Ye§F' if " "J gh i total amount S
T W`!} l J I E
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
, ¤Yes IM
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.
No A! 6
I declare nmder penalty of perjury that the above infomation is truehnd correct.
3!Q{C}.>T_ E
DATE SIGNATURE OF APPLICANT
I CERTIFICATE
(incarcerated applicants only) _
w » ev rw e ·e r A 4 11 . s r T » r er. ea syn r
I certify that the applicant named herein has the sum of S l (D fl Le on account hislher credit at (name
orimamuon) +i Amd I. Q JM Mg Ow reeh incl D giw hdw Cm ,
I further certify that the applicant has the following securities to hislher credit:
I;1 ;r>\ .
I further certify that during the past six months the applicant's average monthly balance was S Q 3 . Ci Y
and the average monthly deposits were S ED · D J .
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Date SIGNATURE OF AUTHORIZED OFFICER
(NOTE TTIEREQUTREMENTIN ITEM 1 FOR THEINMITE TO OBTAINANDATTACHLEDGER SHEETS
OFACCOUNT TRANSACTTONS OVER THEPAST SUT MONTH PERIOD. LEDGER SHEETSARE NOT
REQUIRED FOR CASES FILED PURSUANT T0 28: USC §2254)

I --~= Case 1:05-cv-00013-GIVIS Document 7 Filed 03/18/2005 Page 3 of 3
RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
03/11/05 14:32
ST 007 / OPR KJG
SBI : 506622
Resident Name : LEWIS, JIMMY
Time Frame : 06/25/2004 12:48 - 03/11/2005 14:32
Date Time Type ST OPR Receipt H Amount Balance
06/25/2004 12:48 Recpen 5 WD 82855 1.50 1.50
07/07/2004 06:52 Order 2 IM 823665 1.36 0.14
07/12/2004 15:10 Add 6 PLF F4716 39.71 39.85
07/14/2004 09:23 Order 2 DDT 824914 21.21 18.64
07/19/2004 12:00 Add 4 CK D9846 50.00 68.64
07/20/2004 08:51 Order 2 DDT 825494 14.58 54.06
07/26/2004 13:03 Add 4 CK D10189 30.00 84.06
07/27/2004 13:05 Order 2 IM 826422 22.16 61.90
08/04/2004 08:15 Order 2 WLH 827502 23.36 38.54
08/09/2004 12:28 Add 4 CK D10924 40.00 78.54
08/10/2004 08:06 Order 2 DDT 828073 24.75 53.79
08/12/2004 10:26 Order 9 WAC I149 2.20 51.59
08/17/2004 08:39 Order 2 DDT 829081 28.63 22.96
08/18/2004 11:38 Rec Payment 7 PLF G2806 5.75 17.21
08/18/2004 14:43 Order 2 DDT 829432 2.30 14.91
08/19/2004 12:38 Add 4 CK D11404 20.00 34.91
08/23/2004 09:26 Add 0 RP E-15616 25.00 59.91
08/25/2004 07:55 Order 2 DDT 830311 18.48 41.43
09/01/2004 08:07 Order 2 IM 830951 25.28 16.15
09/15/2004 08:28 Order 2 IM 832918 16.00 0.15
09/17/2004 12:56 Add 4 SED D12896 25.00 25.15
09/21/2004 13:19 Order 2 IM 833682 22.17 2.98
09/22/2004 13:23 Add 4 SED D13102 25.00 27.98
09/29/2004 08:33 Order 2 DDT 834761 14.70 13.28
09/30/2004 13:59 Credit 9 IM I559 2.76 16.04
09/30/2004 14:04 Order 9 IM I561 3.70 12.34
10/06/2004 08:33 Order 2 DDT 835533 7.82 4.52
10/13/2004 09:49 Order 2 DDT 836466 4.41 0.11
10/20/2004 10:41 Add 4 SED D14514 25.00 25.11
10/26/2004 09:04 Order 2 DDT 838042 21.52 3.59
10/27/2004 09:22 Credit 2 WAC 838319 21.52 25.11
10/20/2004 18:31 Rec Payment 7 PLF G3722 14.33 10.78
11/02/2004 08:36 Order 2 WAC 838956 10.59 0.19
11/03/2004 14:16 Credit 9 IM I903 10.59 10.78
11/03/2004 14:19 Order 9 IM I904 10.59 0.19
11/05/2004 09:24 Add 8 RP H7396 25.00 25.19
11/08/2004 13:02 Add 4 CK D15398 30.00 55.19
11/23/2004 08:17 Order 2 DDT 841541 32.74 22.45
11/24/2004 15:36 Rec Payment 7 PLF G4070 19.13 3.32
11/30/2004 11:41 Order 2 WLH 842407 3.10 0.22
12/02/2004 10:29 Rec Pymnt-Rev 7 kjg G4112 14.33 14.55
12/07/2004 08:05 Order 2 WLH 843112 14.51 0.04
12/09/2004 09:38 Credit 2 DDT 843459 14.51 14.55
12/09/2004 11:30 Rec Payment 7 kjg G4129 5.76 8.79
12/17/2004 11:20 Withdrawal 6 PLF F8176 8.49 0.30
12/17/2004 11:31 Add 4 SED D17465 50.00 50.30
12/30/2004 11:24 Rec Payment 7 kjg G4196 1.20 49.10
01/06/2005 12:09 Withdrawal 6 PLF F8432 8.49 40.61
01/13/2005 14:53 Withdrawal 6 PLF F8659 9.37 31.24
01/26/2005 11:24 Rec Payment 7 kjg G4252 20.69 10.55
01/26/2005 11:43 Rec Payment 7 kjg G4253 0.37 10.18
02/10/2005 10:15 Rec Payment 7 kjg G4287 5.80 4.38
02/28/2005 10:57 Add 4 SED D21294 50.00 54.38
03/01/2005 08:52 Rec Payment 7 kjg G4600 18.83 35.55
03/10/2005 05:53 Order 2 DDT 855041 19.29 16.26
03/11/2005 08:48 Credit 3 WLH C6329 0.50 16.76