AO 240 (Rev. 10/G3)
DELAWARE Env. 4/05
IHWITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
@L/$§g_â€7' éég ivy __
Phil mctteml, ::2‘Ial¤t1rrL;# §:Q[;QI:f_’_°*’$*‘· APPLICATION TO PROCEED
mem ‘ ‘ '. ‘v ‘
CARL`; ,l,Q§é%,¢v¤ Hacker? V. bm; Bam Fai; WITHOUT PREPAYMENT OF
(mem. Ierwasqg , Qu |<.H¤·,;# mg; °°¤"¤‘}',§°tBp,°;Rg,¤9¤ FEES AND AFFIDAVIT,
Douj R0
I, pt LEE U"-I- I3 Q Qgk} Ll declare that I am the (check appropriate box)
° if Petitioner/Plaintiff/Movant ° ° 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/petition/motion.
In support of this application, I answer the follocyng questions under penalty of perjury:
l. Are you currently incarcerated? ° °{es ° °No (If "No" go to Question 2)
If "YES" state the place of your incarceration §;iQggm7:p R YQQMC3 Q Oa‘1'7&CLT\g)p xgy§Tt`Vu—§;g[)
Inmate Identitication Number (Required): El 5 -7 75
Are you employed at the institution?NO Do you receive any payment from the institution?
Attach a ledger sheet from the institution of your incarceration showing at least the past six months '
transactions
2. Are you currently employed? ° ° Yes ° Léo
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 ·l‘iNo
b. Rent payments, interest or dividends • • Yes •‘yNo
c. Pensions, annuities or life insurance payments • • Yes •¥yNo
d. Disability or workers compensation payments • • Yes • JN0
e. Gifts or inheritances • · Yes •\yNo
f. Any other sources • • Yes • • No
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.
a Case 1:08-cv-00454-SLR Document 1 Filed 07/22/2008 Page 2 of 3
AO 240 Reverse (Rev. 10/03)
DELAWARE Bev, ·l£05l
4. D0 you have any cash or checking or savings accounts? • • Yes ·i»4lo
If "Yes" state the total amount $ `
5. D0 you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘ /
· · Yes ·|r 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
indicate how much you contribute to their support, OR state NONE if applicable. ,\[C»,V(§`
I declare under penalty of perjury that the above information is true and correct.
(Ti,/ig /7, 9-005* Q/@j é&,;aU*~rL./
DATE SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an aftidavit
stating all assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional
ofiicer 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 :08-cv-00454-SLR Document 1 Filed 07/22/2008 Page 3 of 3
RESIDENT HISTORY REPORT 1**398 1 ¤f 1
HRvc1 ~1‘’
04/22/0815:13 ,~‘°._
ST 006 / OPR JNM ’
SBI : 483775
Resident Name : BROWN, ALBERT J
Time Frame : 10/22/2007 18:58 · 04/22/2008 15:13
Date Time Type ST OPR Receipt # Amount Balance
11/30/2007 18:58 Recpen 5 SMJ E25689 549.32 549.32
12/03/2007 07:55 Order 2 AFC B195056 58.88 490.44
12/10/2007 09:18 Order 2 AFC B196058 47.80 442.64
12/10/2007 11:48 Rec Payment 6 JNM F33718 0.75 441.89
12/13/2007 13:56 Rec Payment 7 SJW G13542 6.00 435.89
12/17/2007 07:26 Order 2 AFC B196925 60.13 375.76
12/24/2007 08:05 Order 2 DDT B197937 57.62 318.14
12/31/2007 07:22 Order 2 DDT B198814 59.67 258.47
01/07/2008 07:46 Order 2 DDT B199805 64.90 193.57
01/10/2008 12:51 Rec Payment 6 JNM F34358 1.00 192.57
O1/10/2008 13:01 Rec Payment 6 JNM F34366 1.00 191.57
01/14/2008 09:03 Order 2 DDT B200827 56.97 134.60
01/22/2008 15:30 Rec Payment 7 SJW G13928 8.50 126.10
01/22/2008 15:31 Rec Payment 7 SJW G13929 17.50 108.60
01/22/2008 15:41 Rec Payment 7 SJW G13935 0.25 108.35
01/24/2008 13:18 Rec Payment ‘ 6 JNM F34947 1.65 106.70
01/24/2008 13:54 Rec Payment 6 JNM F34961 1.65 105.05
01/25/2008 15:43 Rec Payment 7 SJW G14012 2.25 102.80
02/04/2008 08:20 Order 2 AFC B203510 62.09 40.71
02/05/2008 14:08 Order 11 AFC K7221 0.50 40.21
02/05/2008 14:11 Credit 11 AFC K7222 0.50 40.71
02/11/2008 08:44 Order 2 DDT B204426 11.35 29.36
02/18/2008 07:37 Order 2 DDT B205376 26.77 2.59
02/20/2008 15:46 Rec Payment 7 SJW G14417 1.50 1.09
02/29/2008 13:55 Rec Payment 10 bsp J12707 0.50 0.59
03/24/2008 08:55 Order 2 DDT B210269 0.59 0.00
Case 1:08-cv-00454-SLR
Document 1
Filed 07/22/2008
Page 1 of 3
Case 1:08-cv-00454-SLR
Document 1
Filed 07/22/2008
Page 2 of 3
Case 1:08-cv-00454-SLR
Document 1
Filed 07/22/2008
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