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

"#f., I I ii Case 1 :07-cv-00749-JJF Document 21 Filed 12/27/2007 Page 1 of 3
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an 1-to (DEl.»\WAl'LE Rev mnt · i “‘"" ' _________i*—_ i
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UNITED STATES DISTRICT,COURT` T` _ I , t
DISTRICT OF DELAWARE
barred 5774*/I Ts . i
Plaintiff APPLICATION TO PROCEED i
‘ WITHOUT PREPAYMENT OF
V. FEES AND AFFIDAVIT
Defendant(s) CASE NUMBER: ; _ A .
. -} O? Cl/·oo~?~ I, BQFYYAJ 57l@‘?`{’5 _ declare that I am the (check appropriate box) l
E/I’etitioner2 E-laidtiiji/E\/Iow*ant E Other in the aboveentitled proceeding; that in support ofmy *
request to procee without prepayment of fees or costs under 28 USC §l9l5, I declare that I am i E
unable to ay the costs of these proceedings and that I am entitled to the relief sought in the
·etition/motion. l
In support of this application, I answer the following questions under penalty of p rjury: F I l- l D
1. Are you currently incarcerated? QQ C] No (If "No" go to Question 2) , DEC 2 7 2007 I
If "YES" state the place of your incarceration 5;/O?) I l
U.S. DISIRICT ppilgég t
Are you employed at the institution? El Yes [Q*N'; Dmmcl OF DE
Do you receive any payment from the institution? Cl Yes
l Herve the izrsritttrtorz fill out the ce.¤·ri`ficote oortion ofthis affidavit Cl??£7r`C¥l`2°£2C»L? CI fen'? er s/ree: frown)?/ie
fnstz't1¢tiom”s} of voor incarceration s/zowirzv: ot feats! the ods! 5`LYmor2rhs' tmnscrctions. Lec/g er
sheets are not i·ermii·eo’ for crises fi/ed gizrstiom to 28.·£;$C` §2254'.
2. Are you currently employed? [I Yes [E/lf
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. ;\//,4
la. 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 ofyour last employer.
3. in the past 12 twelve months have you received any money from any ofthe following sources?
a. Business. profession or other self-employment Cl Yes in/6
b. Rent payments, interest or dividends Cl Yes D»»P¤‘(
c. Pensions, annuities- or life insurance payments E] Yes EK
d. Disability or workers compensation payments . K] Yes QM
e. Gifts or inheritances El Yes W _
i`. Any other sources Ci Yes iD»islT:>/'V
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. N

( . Case 1:07-cv-00749-JJF Document 21 Filed 12/27/2007 Page 2 of 3
4. D0 you have any cash or checking or savings accounts? E Yes E]/NE? ‘
if "Yes" state the total amount S p l
5. - Do you own any realestate, stocks, bonds, securities, other tinancial instruments, automobiles or l
other valuable property? C3 Yes
if "'Y`es" describe the property and state its value. / S
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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 .\/ONE if applicable.
I declare under penalty of perjury that the above infomation is true and correct. _
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Case 1 :07-cv-00749-JJF Document 21 Filed 12/27/2007 Page 3 of 3
INIVIATE ACCOUNT STATEMENT
DARREN STAATS 23-Oct-07
NAME SCCC ADMIT DATE
467006 l
SB|# DATE RELEASED
· I
I
0ATE osposirs Typ`? gf DISBURSE T_yp° °f sAi.ANcE
Deposit MENT Drsburs. I I
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
‘ $0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0..00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00. $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
TOTAL $0.00 $0.00 $0.00
$0.00
OPENING BALANCE A
$0.00
ACCOUNT BALANCE
TYPE OF DISBURSIVIENTS
R/B room/board owed from previous visits to SWRU
MED = Visits to medical
TRANS = transportation owed from previous vlsits
P2 = Pay to's submitted thru business office
DG = Dollar Generai/commissary
TRANSF Transfers to Other Institutions
SP. COURT Superior Court
TYPE OF DEPOSITS
M/O = money orders received outside of institution
B/R = booking and receivng
CK = checks
CASH
I/W = inmate wages
I
VIOLATION OF PROBATION/SCCC `

Case 1:07-cv-00749-JJF

Document 21

Filed 12/27/2007

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Case 1:07-cv-00749-JJF

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Case 1:07-cv-00749-JJF

Document 21

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