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

Case 1:06-cv-00757-JJF Document 1 Filed 12/11/2006 Page 1 of 2
· AO 2-ID [DELAWARE R.E\.' ?.`¤n3
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE -
Plaintiff APPLICATION TO PROCEED
_ WITHOUT PREPAYMENT OF
V. FEES AND AEFIDAVIT
Defendantfs) CASE NUMB ER: """ O 6 - T 5 T
I, declare that I am the (check appropriate box)
lE@titioner/P1aint"iff»'l*/Iovant [Il Other in the above—entitled proceeding; that in support of my
request to proceed without prepayment of fees or costs under 28 USC § I 915 , 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/petitionfmotion. .
In support of this application, I answer the following questions under penalty of perjury:
I. Are you currently incarcerated? |E"Tes D No (If "No" go to Question 2) A
- `kp _ , tl H
If "YES" state the place of your incarceration i>Ul55€x GJUD 7 CDV -`l‘ ‘‘““‘
Are you employed at the institution'? E Yes E No 5 n I I .=‘I nnnlfihil
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_ _ llElY2tl2@@5 ¤
Do you receive any payment from the institution? El Yes @410 5 Q KD gcanm,4
i - , ___ ___ __ p _ g
Have the instittatinn iff out the cert acme ortiorz of this cr zdavit and article __; E
instimriomjsl of voter irzcczrcemtion .s/towing at least the gust SIX moi·rtf2s' zrrzrzmetions. ``”`i ``‘i“‘ "“‘”‘··i
sheets are not reuz:ii·ee’ for cases fi/er/pnrsirent to 28: USC §2254.
2. Are you currently employed? I] Yes @40
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 it -home A
salary or wave and pay period andfhe name and address of your last employer. /%;%*49 @{9 Q
_b€jd,,,;,:,,»8 - s {5ve. vv W I. tore! l/me/y H?
3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment E Yes EIA No
b. Rent payments, interest or dividends E Yes El/No
c. Pensions, annuities or life insurance payments E Yes @’No
d. Disability or workers compensation payments E Yes (E/No
e. Gifts or inheritances I Cl Yes El”No
f. Any other sources E Yes IQ/No
lf 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.

Case 1:06-cv-00757-JJF Document 1 Filed 12/11/2006 Page 2 of 2
` 4. ‘ Do you have any cash or checking or savings accounts? @’?es El No
lf "Yes" state the total amount 53
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or
other valuable property? I] Yes E 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 st te NO.·\/E if applicable.
‘~ tpl —"r*»‘*° ·/1
V N .- bjur er » ,2.0e¤.— r1wn_ ,.
I declare under penalty of perjury that the above information is true an correct. _
i ”
Date; I Signamre ot`Applicant { _, I-


Case 1:06-cv—00757-JJF Document 1-2 Filed 12/11/2006 Page 1 of 2
_ . · ` ` INMATE ACCOUNT STATEMENT
KEVIN MOORE ` 21-Nov-06
NAME SCCC ADMIT DATE
202242
SB|# DATE RELEASED
Type of DISBURSE Type of
DATE DEPOSITS DG OSH MENT Disbursl BALANCE
$0.00 $0.00 $0.00
12/5/2006 $10.00 Mail/MO $0.00 $0.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 $0.00 $10.00 $10.00
$0.00 ._ $0.00 $10.00 $10.00
TOTAL $10.00 $0.00 $10.00
$0.00
OPENING BALANCE
$10.00
ACCOUNT BALANCE
TYPE OF DISBURSMENTS
R/B room/board owed from previous visits to SWRU
MED = Visits to medicai
TRANS = transportation owed from previous visits
P2 = Pay to's submitted thru business ofHce
DG = Dollar General/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
` VIOLATION OF PROBATION/SCCC

Case 1:06-cv—00757-JJF Document 1-2 Filed 12/11/2006 Page 2 of 2
. r. -
_ A ` V REQUEST FORM p
FOR
INMATE ACCOUNT ACTIVITY STATEMENT
Inmate Name: WQQQ E€»g[;g SBI Number: @0 il O1 ZL
(Last) (First) (M.I.)
Housing Unit: SQ O E E5 gl L
In accordance with Bureau of Prisons Procedure 5.4 entitled “In Forma Pauperis", please provide a
su 1 of my account transactions. _
/ i ,/ - l I l t { {
*1/II A I, -’
Inma e Signature Notary O
Inmate Account Activity Statement will be processed only after staff verifies your legal documents are
complete.
Date received by business office: l .
· INMATE ACCOUNT STATEMENT
TO: Inmate Name: l Qblbl K l{Q,·g/ j in l .
(Last) (First) (M.I.)
SBI Number: l QOZLDLQ gl fl
Housing Unit: § img A
FR: Inmate Account Technician
DA: A
RE: Summary Of Account
Attached is your account statement for the six month period of {\,l<5V , Q
through (0 bg;} { , 900 (0 .
I Utilizing the calculation formula described in BOP Procedure 5.4, your average daily balance for this
period is S Jl {Choo .
Attachment
wamry J • _1 .