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

-· . Case 1 :05-cv-00051-GIVIS Document 6 Filed 03/1 1/2005 Page 1 of 3
,. (Ra. mv) UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
cj'?/7/JPVJ /€ ct//S
riaanarr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
, , FEES AND AFFIDAVIT `
Svhvtey rryijwg erm.
I)efendant(s) W __
CASENUMBER: OJ) ( OG! 6/7/JQ
I, / #7/2117 { E /t,E ¢·1ff—$-I declare that I am thefcheclra pftiwte bor)m
PetitionerlPlaintif£fMovant D Other E H g l ,
in the above-entitled proceeding; that in support of my request to proceed without prepayment _, or iosts
wider 28 USC §1915, I declare that I am tmable to pay the costs of these procee ings . · , to the Y
relief sought in the complaint/petition/motion. T -——·
In support of this application, I answer the fo estions under penalty of perjury:
1. Are you currently incarcerated? Yes D No (If "No" goto Question 2)
If"YES" state the place ofyour incarceration (I. 2-., P0 ggéf M/YUW, DE
Are you employed at the institution? 0 Do you receive any payment from the institution? QO
Qge the institugiggr [ill gy; the cggffacatg gggiog of th;} oaitiorvg ogg attach a ledger sheet {rom glge
igsg`tgrg'g;;(sl of [gg; inggggegion shgggyj g gg [eas; {bg pg; SIX @gths’ trogsgctigns, Ike [edgy sbeg
g` got geguired [0; gasg {fied pgrsuarq tg 2Q;U§Q QJZQS4.
2. Are you currently employed? U Yes IM
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 take-home
salary or wages and pay period and the name and address of your last employer. E
H I / _, gg g ,, __ c 3*/0 /P/?*/f7’l6d/E) ¢!»
/ ('/ J:} I 'DOWA}/JMU D}$7`P/ *:7 S?"?/U/7r?770A-i{-¢g`C)$*6’- GO W/(I /UPW/Avzxgl Nj O7(OB__
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 E1 Yes E!"No
b. Rent payments, interest or dividends D Yes lB"Nb
c. Pensions, annuities or life insurance payments U Yes l3’No
d. Disability or workers compensation payments Cl Yes 13*No
e. Gifts or inheritances El Yes Ei"No
f. Any other sources Cl Yes E1-·‘N6
If the answer to any of the above is "YES" describe each source of money and state the amount
received AIG) what you expect you will continue to receive.


> ·· Case 1 :05-cv-00051 -G MS Document 6 Filed 03/1 1/2005 Page 2 of 3
4. Do you have any cash or checking or savings accounts? ¤Yes ¤rI%/
If "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
¤Yes BN?
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.
xvcw
I declare under penalty of perjury that the above information is true and correct.
DA E SIGNATURE OF APPLICANT
CERTIFICATE
(Incarcerated applicants only)
(Z 0 be completed ky the fgsg'tutg`_qn of incoggerajon)
I certify that the applicant named herein has the sum of S (7/‘ 3 9 on account hisfher credit at (name
7 • e-—*
of institution) éiO é’—J'ft.-VGF il ZO"‘€J/`* CJ t" I/6 C»7lf C?/Wit / .-iiifz/7LLr Z7d»~¤..
I further certify that the applicant has the following securities to hisfher credit:
I further certify that during the past six months the applicant‘s average monthly balance was $ 3 [ » cg O
andthe average monthly deposits were S L/fg · 7é/ .
5 [S [ BOOST gi/>,¢.42mggc¤. ¤£·Q4.-4,4
Da e SIG ATURE OF AUTHORIZED OFFICER
(NOTE HIE REQUIREMENT IN I TEM I FOR THE INM4 TE TO OBTAINANDAITACHLEDGER SHEETS
OF ACCOUNT TRANSACTIONS OVER IHEPAST SIX MONTH PERIOD. LEDGER SHEET SARE NOT
REQUIRED FOR CASES FILED PURSUANT TO 28: USC §2254)


Case 1:05-cv-00051-GIVIS Document 6 _ Fnled 03/11/2005 Page 3 of 3
RESIDENT HISTORY REPORT Page 1 0f 1
HRYCI
03/01/05 15:45 _
ST 006 / OPR PLF
SBI : 506622 -
Resident Name : LEWIS, JIMMY
Time Frame : 06/25/2004 12:48 - 03/01/2005 15:45 {
W
Date Time Type ST OPR Receipt {I 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 {
W 08/09/2004 12:28 Add 4 CK D10924 40.00 78.54 :
“§§§ S 08/10/2004 08:06 Order 2 DDT B28073 24.75 53.79 :
08/12/2004 10:26 Order 9 WAC I149 2.20 51.59 1
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 I
08/19/2004 12:38 Add 4 CK D11404 20.00 34.91
oa/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 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 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 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 B38319 21.52 25.11
10/2B/2004 18:31 Rec Payment 7 PLF G3722 14.33 10.78
11/02/2004 08:36 Order 2 WAC B3B956 10.59 0.19
11/03/2004 14:16 Credit 9 IM I903 10.59 10.78
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
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 E43112 14.51 0.04
12/09f2004 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
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
2/10/2005 10:15 Rec Payment 7 kjg G4287 5.80 4.38
02/za/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