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

— Case 1:05-cv-00219-KAJ Document 1 Filed 04/13/2005 Page 1 of 2
AO ZJUIDELAWARE REVTUO)
I UNITED STATES DIST · I . .1 - _ ..._
DISTRICT OF DELA ·’·* ? ‘
Plaintiff 22 _ I
WITHOUT P IPAYMENT OF
V. FEES AND AFFIDAVIT
Defendantts) CASE NUMBER: O 5 — 1 9 I
E/I, g’(‘€’ vi A fg O IA declare that I am the (check appropriate box) L
Petitioner/Plaintiff/Movant Cl Other in the above-entitled proceeding; that in support of my
request to proceed without prepayment of fees or costs under 28 USC §l915, I declare that I am
unable to pay the costs ofthese proceedings and that I am entitled to the reliefsought in the
complaint/petition/motion.
In support ofthis application, I answer the following questions under penalty ofpezjury: i
I
I. Are you currently incarcerated? [2% [1 No (If"No" goto Question 2)
If "YES" state the place ofyour incarceration B ‘€..kCLLLx cxx wc Q. C K9 {meg t 0 walk C JQ ti
I
Are you employed at the institution'? I] Yes [E60 I
Do you receive any payment from the institution? CI Yes iEl’§
Hove the institution [zi! out t/ze certitzcote portion of this of/idovit and ottoch o ledger sheet Qom the I
irrstittttiontsj of vour incarceration s/zowirzv at [east the oost S/X mont/is' transactions. Ledver
sheets are not reotiired {or cores [tied gtirszmnt to ZSJUSC §2254. I
2. Are you currently employed? [1 Yes @46
a. Ifthe answer is "YES" state the amount ofyour take-home salary or wages and pay period and
give the name and address of your employer.
b. Ifthe answer is "NO" state the date ofyour 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 I2 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self—empIoyment I] Yes lE’Tio
b. Rent payments, interest or dividends Cl Yes lH’Elo
c. Pensions, annuities or life insurance payments KI Yes El·’No
d. Disability or workers compensation payments I] Yes @0
e. Gifts or inheritance yes No
f. Any other sources 0\it&/\—€ tc, 0 Yes I] No
Gl Vx OL OAS ‘
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.
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. Case 1:05-cv-00219-KAJ Document 1 Filed 04/13/2005 Page 2 of 2
DELA WARE C ORRE C T I ONAL CENTER
S UPPOR T SER VI CES OFFICE
MEM ORAND UM
To.- 3;)}/\§ ¥];]g]A.g‘ FROM: Stacy Shane, Support Services Secretary
RE: 6 Motztlis Account Statement i
DA Te.- _@]@Q.A{\ QA , SOO)! T .
Attached are copies ofyottr inmate account statementfor the months of
Thefollowing indicates the average daily balances.
MONTH A VERA oe DAILYBALANCE
`1 ~ Be — SQJ
cs — ."¤>\
mw -. Sa
15 it L (Q .
gi b B s E Q
Average daily balances/6 months: /l
Attachments
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