q¤.v.4m; UNITED STATES DISTRICT COURT
eeeee s --0 Y < eeeee 2 0 s at eeee as PETRICT QE DELAWARE
5/31;*1 5131393 ` EEEE A tw" I "E ```E U E7"? *2 [6F` T E I
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Plaintiff APPLICATION TO PROCEED
V. E VVITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT s
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Defendant(s)
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in the above-entitled proceeding; that in support of my request to pro · o :·_ costs
\·¤ld€|’28 USC §I9lS, I tlcdaltthatl am unable to pay the costs ofthese p ·‘ a‘ ·i‘is1 { "wr ;" ‘i;w· ‘ · wg on l" ·, to the
relief sought in the complaintlpetition./motion.
In support of this application, I answer the followingquestions under penalty of perjury:
1. Are you currently incarcerated? E/Yes El No (If "No" go to Question 2)
If "YES" state the place of your incarceration ll Oubga PQ Q , Ego gg { igp g;;:§:‘ m {EQ | gg 5 gg
Are you employed at the institution? u ¤:5>__ Do you receive any payment from the institution?{_‘3 Q-Lt %‘e1‘
l I .! u‘ I 1, 11 --ruf f: 1Ul.¤‘ :‘[4!.-!. 1 FLY Kraft: !!1 !!l !1 U' 'f’@_ ‘2
2. Are you currently employed? U Yes M
l 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 of your last employment, the amount of your take-home
salary or wages and pay period and the name and add s of your last employer. ‘ A
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3. In the past 12 twelve months have you received any money from ag o th3foll%t?in ? M l\W`—pb
a. Business, profession or other self-employment ¤ Yes WH0
b. Rent payments, interest or dividends ¤ Yes ¤/’1§I0
c. Pensions, annuities or life insurance payments ¤ Yes 2/ No
d. Disability or workers compensation payments El Yes nr/glo
e. Gifts or inheritance-s CI Yes l¤’JNo
f. Any other sources . El Yes ¤/ No
If the answer to any of the above is "YES" describe each source of money and state the amount
received AAD what you expect you will continue to receive
Case 1 :07-cv—OO220-SLR Document 1 Filed O4/25/2007 Page 2 of 2
4. Do you have any cash or checking or savings accounts? ¤Yes l¤’l
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
, ElYes B16
If "Yes" describe the property and state its value.
p 6. List the persons who are dependent on you for support, state your relationship to each person and
ydicate how much you contribute to theirsupport, OR state NONE if applicable. `
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C_DV\‘\:\é..~\,gJu..4__,-i;(·3"_ _____V V
I deiigie under penalty of perjury that the above infomation is true and correct.
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DATE " *' = " “ ·"· " · PLICANT
g ~ CERTIFICATE `.
(Incarcerated applicants only)
u I certify that the applicantnamed herein has the sum of S E on account hisfher credit at (name
ofinstitution) ggél I y .
I further certify that the applicant has the following securities to hislher credit: " `
I further certify that during the past six months the applic.ant's average monthly balance was S QC
t and the average monthly deposits were S - g 2. g QQ . t
} _ / / / / ‘ ..
@@0407 0rL» an ..,m— rm.} 0
Date . SIGNATURE OF AUTHORIZED OFFICER
(NOTE IHEREQUIREMENTINHEM1 FOR THE IAMATE T0 OBTAINAMJATIACHLEDGER SHEETS
OFACCOUNT TR.4N;SACTIO1\S OVER THE PAST SIX MONTH PERIOD. LEDGER SHEETS ARE NOT
REQUIRED FOR CASES FILED PURSUANT TQ 28: USC §2254)
Case 1:07-cv—O0220-SLR Document 1-2 Filed O4/25/2007 Page 1 of 1
RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
04/zo/07 13:06
ST 006 / OPR KJG
SBI : 231393
Resident Name : BROWN, ROBERT D
Time Frame : 03/23/2004 12:47 - 04/20/2007 13:06
Date Time Type ST OPR Receipt # Amount Balance
03/23/2004 12:47 Intake 4 CK D3835 30.00 30.00
03/30/2004 06:14 Order 2 DDT B10660 29.82 0.18
04/12/2004 12:18 Order 2 DDT B12397 0.13 0.05
04/17/2004 10:12 Credit 2 DDT B13140 0.13 0.18
08/08/2005 01:00 Add 5 CNC E9789 5.00 5.18
08/22/2005 09:35 Close 6 kjg F13583 5.18 0.00
08/22/2005 14:29 Close—Rev 6 kjg F13598 5.18 5.18
02/08/2006 04:48 Add 5 bxd E13183 85.00 90.18
02/13/2006 06:25 Order 2 DDT B101018 59.93 30.25
02/16/2006 11:44 Credit 2 DDT B101883 59.93 90.18
02/16/2006 11:46 Close 6 kjg F16896 90.18 0.00
08/23/2006 14:29 Add 4 SED D53371 25.00 25.00
08/29/2006 05:46 Order 2 WLH B130238 24.75 0.25
09/08/2006 11:52 Add 4 SED D54216 20.00 20.25
09/11/2006 06:41 Order 2 WLH B132017 20.12 0.13
09/14/2006 13:59 Rec Payment 10 bsp J5715 0.10 0.03
10/24/2006 13:21 Add 4 SED D57025 10.00 10.03
10/25/2006 13:53 Rec Payment 10 bsp J6448 2.00 8.03
10/27/2006 15:25 Rec Payment 10 bsp J6488 1.35 6.68
10/30/2006 06:32 Order 2 WLH B139143 6.27 0.41
12/15/2006 13:57 Add 8 bsf H26670 22.00 22.41
12/18/2006 06:34 Order 2 WLH B146376 22.21 0.20
01/05/2007 12:31 Add 4 SED D61370 50.00 50.20
01/08/2007 06:19 Order 2 DDT B149338 35.89 14.31
01/15/2007 06:32 Order 2 DDT B150422 7.49 6.82
01/19/2007 09:35 Rec Payment 10 bsp J8030 0.50 6.32
01/22/2007 06:55 Order 2 DDT B151512 _ 6.30 0.02
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