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

Vis" t "` Case 1:05—cv-00052>G|\}l$* U BdcQmei’*n1_§ Filed O_3/11/2005 Page 1 of 3
I DISTRILT Ob DELAVv.—\R.E
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I Planted APPLICATION TO PROCEED
f V. V/`ITHOUT PREP.~\YDvlENl` OF
FEES AND .~\FFID.—\VIT
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CASE AUNIBER; Q5-- gjkfgc 6,44 S
1, 77/7/M7 /6 {Q W JS deem em 1 am me qeaeezeaa .=¤r5a.;s__ l_y_q_;_)
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Qéedtioner/Plaintiffxliiovant El OUR? . _ - gl .
in {bc lbqve-entitled proceeding; that in support of H1? Foquest to proc.e.·:d vrithout repayment of fx or egg;
mes; 23 USC §1915, I decL·:u—e that I am unable to pay time costs of these proe;:,~·iings - · ai —_s= ;
,-guar Sought in the complint/pettdon/moiio¤¢ ` i _ _ e _¥_, ___
In support of this application, I answer the fo ons under penalty ofperjury;
1_ Are you currently incarcerated? YG -_ lj No (If "No" go to Question 2)
1r~Yas·· mee ure place ofyour incarceration HF- V·C'.??, R0 Bog Qsel L4//cm', by @@07
Are you employed at the institution? @0 Do you receive any payment from the institution? AK)
Hm; {Q; in;;r.g` ufign [QI gut [fr; ggrjficcrfg ;gg_:;__rgg' g Qt [bp'; Giddbif ggd mach n Lzdgg gfxgi-:1* [rpm Zh:
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2. Are you currently employed? lj Yu lilrtdr ’
l a. If the answer is *·ras*· state the amount ofyour talce—home salary or wages and pay period and
give the name and address of your employer. l
b. If the answer is "NO" state the date ofyour Last employment, the amount ofyour take-home
salary or wages and pay period and the name and address ofyour last employer.
/I/I ea WWNWWU bl $7/7/f7'5V‘?11//E4~T7&v(] #3 $72 00 WK ,`?q& /EAW/n&y?—.gU/D I
/ ./ / A/6*W4z;<_/ IUJ- 0 7/O}
3. In the past 12 twelve months have you received any money from my ofthe following sources?
_ L Business, profession or other aeltiemployment Cl Yes G’Ft°o l
b. Rent payments, interest or dividends CJ Yes Z/lfio
e. Pensions, annuities or life insurance payments Cl Yes @60 1
cl. Disability or workers compensation payments Cl Ym C4/Q l
e. Gifts or inheritance: Cl Yes IZ/do ‘
F. Any other sources ¤ Yes (Fo
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 co ntiuue to receive.
»-——-————-»———— -- ·· it

Case 1:05-cv-00052-GIVIS Document 6 Filed O3/11/2005 Page 2 of 3 -
'< U "‘;';s" stat: the totnl Jimnunt S .’ `*I ‘
L Dr) YOU CWT1 lily F&L£Ll LSLALQ, rtoclts, lf)GF1d5, S;ZCUfiCl€-S, OLl“1¢;:‘ l'.LD:1¤C.l1l tD_'iU'L1.LI1CI1i.‘i, 1LI{Dl’T|ObiIdS Ol' Othgp -
nl . bl roperty? U
. V uq .d P GYe.~1 C3'?
If "Yes" describe the property and state its value.
6_ List the persons who src 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.
M /»/E
I declare under penalty ofperjury that the above information is true and correct. i
3 O 5 { ‘7*'7·"»—4-··r»··- /4-t ,5
on Y SI 'I'U ' FAPPLICL~*tN'1` U
- . CERTIFICATE _ no y
- (Incnrcerated applicants only) ___ .
(IQ Q4 Qgganftdgd Qu {Q; Q gg ugfgg Q[;'gg•;-Eggyign) ·
. . i . 4 3 51 .· . Q
I certify that the applicsmt named here-.u1 has the sum 0fS _ · qq ggcgunt ing/her credit at (name P
. ' ·. L . ,7 V
Orimnmnou) /Cl(l Q/UA f(?/ ll gv C/UQ Career-1~ rarrwi { ZJ/"Sf J /!i¢'{?‘·¤·~ , ; =
I further certify that the applicant has the following securities to liisfher credit: l
M//2 . _ . _ i
I further certify that during the past si: mouths the applicant': average monthly balance was S Q I ' $/0
and the nverage monthly deposits were S ‘ 7 L! , I n V
. n - l i
3 gi? [9005 l ‘?2>,.n:1c:zg/at ¤>£~ youu ii
_ ate SIGNATURE OF AUTHORIZED OFFICER l
QVOIE IHEREQUIREAIENTD/IKM! FOR IHIPGMIE TO OBTAINANDATIHCHLEDGER SHEETS C
OFACCOUNT TRA.NSAC`UON1S' OVER THEPASTSIXAIOMHPERIOD. LEDGEZR SHEETSAREP·"OT
REQUIRED F OR CASE? FILED PURSUANT TO 23.-USC §2254)

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, Case 1:05-cv-00052-GIVIS Docutnent 6_ Filed 03/11/2005 Page 3 of 3
RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
O3/O1/05 15:45
ST 006 / OPR PLF
SBI : 506622
Resident Name : LEWIS, JIMMY
Time Frame : 06/25;*2004 12:48 — 03/01/2005 15:45
nate Time Type ST DPR Receipt # Amount: Balance
06/25/2004 12:48 Recpen 5 WD E2855 1.50 1.50
07/07/2004 06:52 Order 2 IM B23665 1.36 0.14
07/12/2004 15:10 Add 6 PLF F4716 39.71 39.85
07/14/2004 09:23 Order 2 DDT B24914 21.21 18.64
07/19/2004 12:00 Add 4 CK D9846 50.00 68.64
07/20/2004 08:51 Order 2 DDT B25494 14.58 54.06
07/26/2004 13:03 Add 4 CK D10189 30.00 84.06
07/27/2004 13:05 Order 2 IM B26422 22.16 61.90
08/04/2004 08:15 Order 2 WLH B27502 23.36 38.54
I 08/09/2004 12:28 Add 4 CK D10924 40.00 78.54
`““%§¤@8/10/2004 08:06 Order 2 DDT B28073 24.75 53.79
08/12/2004 10:26 Order 9 WAC 1149 2.20 51.59
08/17/2004 08:39 Order 2 DDT B29081 28.63 22.96
08/18/2004 11:38 Rec Payment 7 PLF G2806 5.75 17.21
08/18/2004 14:43 Order 2 DDT B29432 2.30 14.91
08/19/2004 12:38 Add 4 CK D11404 20.00 34.91
OB/23/2004 09:26 Add 8 RP H5616 25.00 59.91
08/25/2004 07:55 Order 2 DDT B30311 18.48 41.43
09/01/2004 08:07 Order 2 IM B30951 25.28 16.15
09/15/2004 08:28 Order 2 IM 832918 16.00 0.15
09/17/2004 12:56 Add 4 SED D12896 25.00 25.15
09/21/2004 13:19 Order 2 IM B33682 22.17 2.98
09/22/2004 13:23 Add 4 SED D13102 25.00 27.98
09/29/2004 08:33 Order 2 DDT B34761 14.70 13.28
O9/30/2004 13:59 Credit 9 IM I559 2.76 16.04
09/30/2004 14:04 Order 9 IM I561 3.70 12.34
10/06/2004 08:33 Order 2 DDT B35533 7.82 4.52
10/13/2004 09:49 Order 2 DDT E36466 4.41 0.11
10/20/2004 10:41 Add 4 SED Dl4514 25.00 25.11 ·
10/26/2004 09:04 Order 2 DDT B38042 21.52 3.59 }
10/27/2004 09:22 Credit 2 WAC B38319 21.52 25.11
10/28/2004 18:31 Rec Payment 7 PLF G3722 14.33 10.78
11/02/2004 08:36 Order 2 WAC B38956 10.59 0.19 M
11/03/2004 14:16 Credit 9 IM I903 10.59 10.78 E
11/03/2004 14:19 Order 9 IM I904 10.59 0.19
11/05/2004 09:24 Add 8 RP H7396 25.00 25.19 1
11/08/2004 13:02 Add 4 CK D1539B 30.00 55.19 {
11/23/2004 08:17 Order 2 DDT B41541 32.74 22.45 H
11/24/2004 15:36 Rec Payment 7 PLF G4070 19.13 3.32 1
11/30/2004 11:41 Order 2 WLH B42407 3.10 0.22
12f02/2004 10:29 Rec Pymnt-Rev 7 kjg G4112 14.33 14.55 ·
12/07/2004 08:05 Order 2 WLH B43112 14.51 0.04 ‘
12/09/2004 09:38 Credit 2 DDT B43459 14.51 14.55
12/09/2004 11:30 Rec Payment 7 kjg G4129 5.76 8.79
12/17/2004 11:20 Withdrawal 6 PLF F8176 8.49 0.30 1
12/17/2004 11:31 Add 4 SED D17465 50.00 50.30 {
12/30/2004 11:24 Rec Payment 7 kjg G4196 1.20 49.10
01/06/2005 12:09 Withdrawal 6 PLF F8432 8.49 40.61
01/13/2005 14:53 Withdrawal 6 PLF F8659 9.37 31.24
01/26/2005 11:24 Rec Payment 7 kjg G4252 20.69 10.55 ‘
01/26/2005 11:43 Rec Payment 7 kjg G4253 0.37 10.18
*¤é§§*02/10/2005 10:15 Rec Payment 7 kjg G4287 5.80 4.38
02/28/2005 10:57 Add 4 SED D21294 50.00 54.38 _
03/01/2005 08:52 Rec Payment 7 kjg G4600 18.83 35.55
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