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

Case 1:06-cv—00701-SLR Document 1 Filed 11/20/2006 Page 1 of 2
i L-‘AO {Ren'? [D/D3)
DELAWARE Eev. 4;*05 `
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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_ Plaintiff APPLICATION TO PROCEED
V. w , VVITHOUT PREPAYMENT OF
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Qiigiioa Baha) will ia ga. Da Lanai;-/Castia, FEES Ann Aamoavrr
A ~ ‘ `- ,, _ Defendant(s) 1 _ - G G — 7 O ll
imihmh jim?) and Do Haqdqgy casa NUMBER:
I, ktlngig 5 Qin, { lg' declare that I am the (check appropriate box)
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ml Petitioner/Plaintiff/Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without L '``.'
28 USC §l9l5, Ideclare that I am unable to pay the costs of these proceedings {Z d th t his s ····
sought in the com laint/petition/motion. _
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W Srciararr .
In Snppn;1 of this application, I answer the following questions wldsf PGHEUY of ll
_ -, _ . DEMWE E =
l. Are you currently incarcerated? ° Yesr °No (If "No" goto Ques l`‘‘ me » ·e~- A ·---- ~-W.
If "YES" state the place of your incarceration ·i;i;gj)tnJ`il/`[J ig; lining C¤fl"Q-C>i§.{3lng_ti in S‘i`!ri’l'»l It lj W
Inmate Identification Number (Required): i 9*
Are you employed at the-institution? Ale Do you receive any payment from the institution? /\/ii') `
Attach a ledger sheet {fom the institution of your incarceration showing at least the past six months ’
transactions _
2. Are you currently employed? ° ° Yes A
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.
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7/'H /6% Glol¤a.i Seluirtone Ll B? C. W Sis Wilwngpa QE ltlyal I Y '”"""Q' FM ”’*€»~
3. In the past l twelve months have you received any money from any of e fo owing sources? Q wa; O`YrfE§€JJ]E
a. Business, profession or other self-employment • • Yes • • No Ms Fchtir
b. Rent payments, interest or dividends · · Yes · · f ij
c. Pensions, annuities or life insurance payments · • Yes • o
d. Disability or workers compensation payments • • Yes · · og!
e. Gifts or inheritances • · Year) • • o' `
f.` Any other sources • ·@- · · 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.
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{ Case 1:06-cv—00701-SLR Document 1 Filed 11/20/2006 Page 2 of 2 i t
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I AO 240 Reverse [Rev. 10/D3)
DELAWARE gev. 4/G5 .
l 4. D0 you have any cash or checking or savings accounts? • · Yes
If "Yes" state the total amount $ ' .,,..
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? i fa
_ • • Yes @ N
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,
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I declare under penalty of perjury that the above information is true and correct.
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DATE · SI NATURE OF PLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
of ticer 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 certitied
statement of each account.

Case 1:06-cv-00701-SLR Document 1-2 Filed 11/20/2006 Page 1 of 1
RE8IDENT`HISTORY REPORT Page 1 of 1
HRYCI
11/OG/06 11:58
ST 007 / 01=12 Jam
S8I : 141273
Resident Name : BURLEY, CHARLES r) B T 0 1
Time Frame : 07/29/2006 14:07 - 11/06/2006 11:58 *~ _ ~
Date Time Type ST OPR Receipt # Amount Balance
07/29/2006 14:07 Recpen 5 CCB E16407 15.51 15.51
08/02/2006 05:49 Order 2 WLH 8126659 8.90 6.61
08/04/2006 09:18 Credit 3 WLH C13671 8.90 15.51
08/07/2006 09:19 Add 8 bef H23252 30.00 45.51
08/07/2006 09:20 Add 8 bef H23253 50.00 95.51
08/11/2006 05:43 Order 2 WLH 8127985 42.51 53.00
08/11/2006 09:49 Credit 11 WLH K154 42.51 95.51
08/16/2006 08:41 Order 2 DDT 8128940 50.90 44.61
08/18/2006 12:35 Add 4 SEA D53091 25.00 69.61
08/22/2006 11:23 Order 2 DDT 8129641 45,83 23.78
08/30/2006 06:53 Order 2 WLH 8130826 23.67 0.11
09/08/2006 13:40 Credit 2 WLH 8131908 50.90 51.01
09/12/2006 09:30 Rec Payment 7 jmh G10949 6.00 45.01
09/13/2006 09:00 Order 2 WLH 8132628 42.72 2.29
O9/14/2006 13:27 Rec Payment 10 bsp J5694 1.00 1.29
09/15/2006 10:49 Credit 11 DDT K874 1.30 2.59
09/15/2006 10:50 Credit 11 DDT K875 3.28 5.87
09/20/2006 09:26 Order 2 WLH 8133820 3.98 1.89
09/26/2006 09:23 Order 2 WLH 8134597 1.86 0.03
10/06/2006 10:29 Add 8 bef H24775 25.00 25.03
10/10/2006 12:50 Order 2 DDT 8136888 20.38 4.65
10/11/2006 08:47 Rec Payment 10 bsp J5972 2.50 2.15
10/12/2006 14:33 Credit 11 DDT K1372 1.53 3.68
10/16/2006 08:47 Rec Payment 10 bep J6261 1.00 2.68
10/23/2006 11:53 Rec Payment 10 bsp J6388 2.50 0.18
10/25/2006 13:35 Add 4 SED D57097 25.00 25.18
10/25/2006 13:56 Rec Payment 10 bsp J6449 6.50 18.68
10/31/2006 07:32 Order 2 WLH 8139935 17.05 1.63
11/02/2006 12:49 Credit 11 DDT K1742 1.05 2.68