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

Cas. 1'Q1js.ci;.00oE1-Gill/Ig ”` acJA»é¤{ vi` ?ieaI6§ 1IéE66 I“`
A (aa. we UNITED STATES DISTRICT COUR yi ._ [
DISTRICT OF DELAWARE _ M ""“’ `‘`· ‘“‘ 5
J · 3 O
if / ’"“ "“"” ’E MS 1. . . .
Plaintiff APPLICATION TO" ’ · • - p=
_ V. PREPAYMENT’ OF
, ,.A y _ _, *·ii`EES'ANB AHHDAVIT
S7j@1§[ 'fxijzég. ,crT?i¢i .. y _y
Defendant(s) . ‘ g _
CASE NUMBE ` -—— C9.3" / — 6
I, Q- i f /5 declare that I am the (check appropriate box)
E/PetitionerIPlaintifflMovant U Other `
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC§191S, I declanethatl am tmableto pay the costs of these proceedings and that I am entitled to the
relief sought in the complaintlpetitionlmotion. ° '
In support of this application, I answer the fo ucstions under penalty of perjury:
1. Are you currently incarcerated? Yes U No (If "No" go to Question 2)
If "YES" state the place of your incarceration /i”—*g»{· Z 1).0 56X Q AW! /[/V 6/GW DZ. / é .·Ffil?
Are you employed at the institution? [J O Do you receive any payment from the institution? /*-7%
I tl i 1 A LM '; I . fa. 1 Aa! .f.*z!. uhll lu ’ .1 fl.f.'| tif {J! .x { ..{ ' 4 [1, ad, I [I1 .1 ‘°
1 `l l..! *1 ` F ·•‘ . 1 ·hr.a•:.·e *!! ·•': ‘1 #1.1.1 ‘ *! .-1*.1 1 A Il., 1. 1 lt H1 Fel t: . ,1 t' =e 1 H
2. Are you currently employed? E Yes D No
- 9
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. _
ia. If the answer is ”N0” state the date of your last empioyment, the amount of your take—home
salary or wages and pay period and the name and address of yyur I yeg B6 O
_ _ I , , p U I _ Ph A I .-0- , V _ _ 0 ,y» .. M
[1// L//g }/ JJMAUYJ/Lf Jl/5 /7Z/Cf S/} 41/IG i QS OU Uk / ig; gm. /L/17. 0 T /d 3
3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment ¤ Yes ¤’Ho
b. Rent payments, interest or dividends 1:1 Y - sible
c. Pensions, annuities or life insurance payments ¤ Yes No
d. Disability or workers compensation payments 1:1 Yes IT/N0
e. Gifts or inheritanees D Yes B/No
f. Any other sources ¤ Yes ¤/No
If the answer to any ofthe above is "YES" describe each source of money and state the amount
received AAD what you expect you will continue to reeeive.

Case 1 :05-cv-50051 -G MS Document 7 Filed 03/ 1 8/2005 Page 2 of 3
4. Do you have any cash or checking or savings accounts? DYes D6 l
If "Yes" state the total amount $___
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
, ¤Yes U6
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. ·
wow G
I declare under penalty of perjury that the above information is trueimd correct.
·-2 Bf O 5/ —, · . ;•1/—--·€. · .
7 DA%; E SKQATURE OF APPLICANT
‘ CERTIFICATE
(Incarcerated applicants only) _
•’# 911.* 4 tu 1 1 H - { *1 I 1 •:!! a-I M 11
I certify that the applicant named herein has the sum of S l (O — nl Le on account hislher credit at (name
ofinstitution) jl;lkJl.J@crel R. Q.fLm<`] C Jy fC c 0 Jhlyh rj.gE·l1‘llLlW JIM _
I further certify that the applicant has the following securities to hisfher credit:
N g 1% .
I further certify that during the past six months the applicant's average monthly balance was S 2 S .0; A)
and the average monthly deposits were S BD. O Q .
2% /l£1)S— aeglléa % ibm
ate SIGNATURE OF AUTHORIZED OFFICER
(NOIE IHEREQ LNIIEM I FOR IHEIMMATE TO OBIAINANDAITACHLEDGER SHEETS
OFACCOUNT IRAMSACIIONS OVER IHEPAST.S1XMONIH PERIOD. LEDGER SHEEISARE NOT
REQUIRED FOR CASES FILED PURSUANT T0 28: USC §2254)

Case 1:05-cv-00051-GMS Document 7 Filed 03/18/2005 Page 3 of 3
RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
03/11/05 14:31
ST 007 / OPR KJG
SBI : 506622
Resident Name : LEWIS, JIMMY
Time Frame : 06/25/2004 12:48 - O3/11/2005 14:31
Date Time Type ST OPR Receipt {I Amount Balance
06/25/2004 12:48 Reopen 5 WD E2B55 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 cx 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 D101B9 30.00 84.06
07/27/2004 13:05 Order 2 1M B26422 22.16 61.90
08/04/2004 08:15 Order 2 WLH B27502 23.36 38.54
08/09/2004 12:28 Add 4 CK D10924 40.00 78.54
08/10/2004 08:06 Order 2 DDT B2!3073 24.75 53.79
08/12/2004 10:26 Order 9 WAC I149 2.20 51.59
08/17/2004 08:39 Order 2 DDT 529081 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 E29432 2.30 14.91
08/19/2004 12:38 Add 4 CK D11404 20.00 34.91
08/23/2004 09:26 Add 8 RP H5616 25.00 59.91
06/25/2004 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 B32918 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
09/30/2004 13:59 Credit 9 IM 1559 2.76 16.04
09/30/2004 14:04 Order 9 IM 1561 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 B36466 4.41 0.11
10/20/2004 10:41 Add 4 SED D14514 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 1338319 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
11/03/2004 14:16 Credit 9 1M 1903 10.59 10.78
11/03/2004 14:19 Order 9 1M 1904 10.59 0.19
11/05/2004 09:24 Add 8 RP H7396 25.00 25.19
11/08/2004 13:02 Add 4 CK D15398 30.00 55.19
11/23/2004 08:17 Order 2 DDT B41541 32.74 22.45
11/24/2004 15:36 Rec Payment 7 PLF G4070 19.13 3.32
11/30/2004 11:41 Order 2 WLH B42407 3.10 0.22
12/02/2004 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 1241459 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
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
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
03/10/2005 05:53 Order 2 DDT B55041 19.29 16.26
03/11/2005 08:48 Credit 3 WLH C6329 0.50 16.76