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

Case 1:08-cv-00558-UNA Document 1 Filed O9/O3/2008 Page 1 of 2 _ V
AO240(Rev.10/03) F · 1`V’
DELAWARE ev, 4 05
SEP — 32008 {
UNITED STATES DISTRICT COURT I
DISTRICT OF DELAWARE u i§*niitit"‘t*To
_ DISTRICT OF DELAWARE
Piarmrrr APPLICATION TO PROCEED
.. _ V. WITHOUT PREPAYMENT OF
ltlgrgggl FEESANDAFFIDAVIT
Defendant(s) . .. r·· 8
CASE NUMBER: · O 8 5 O
I, S I NAI I Z] I I Ig declare that I am the (check appropriate box)
M4 Petitioner/Plaintiff/Movant ° ° Other
in the above—ent”itled 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 of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? °`/Yes ° °No (If "No" go to Question 2)
If "YES" state the place of your incarceration I;I I 3 Y I
Inmate Identification Number (Required): Q 2 (/2
Are you employed at the institution? O Do you receive any payment from the institution? N O
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast silt months'
transactions /
2. Are you currently employed? ° ° Yes T No
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
l salary 0; wages and pay period and the name and address of your last employer.
c.T`/ot 5 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 @0
b. Rent payments, interest or dividends • • Yes • No
c. Pensions, annuities or life insurance payments · · Yes ·?lo
d. Disability or workers compensation payments • • Yes f' No
e. Gifts or inheritances • · Yes {*910
f. Any other sources · • Yes · · 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.

Case 1 :08-cv-00558-UNA Document 1 Filed O9/O3/2008 Page 2 of 2
AO 240 Reverse (Rev. 10/03)
DELAWARE Bev. MD5)
4. Do you have any cash or checking or savings accounts? • • Yes A40
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 Wo
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.
N o N E
I declare under penalty of perjury that the above information is true and correct.
DATE SIGNATURE OF APPLICANT
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
ofticer 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 certified
statement of each account.

Case 1 :08-cv- O5 A g)p®gne/Kt 1- Filed 09/03/2008 Page 1 0f 1
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RESIDENT HISTORY REPORT U_3,:;:>:1?<$’Q£V\%%Rg; Page 1 ¤f 1
ln. ¥.¥. ___A__;;
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08/27/0811:50 Q _ .. '``_ Q .·
ST 006 / OPR JNM `*~<.f;.._;._,-S_;i.f¥*’
SBI : 364290
Resident Name : METTS, SHAUN
Time Frame : O3/01/2008 07:56 - 08/27/2008 11:50
Date Time Type ST OPR Receipt # Amount Balance
03/15/2008 07:56 Reopen 5 bxd E27754 5.35 5.35
04/28/2008 07:38 Order 2 AFC B214952 5.31 0.04
05/05/2008 11:49 Rec Payment 10 bsp J13467 0.04 0.00
05/08/2008 12:13 Add 4 jxs D89381 30.00 30.00
05/08/2008 12:13 Rec Payment 4 jxs D89382 0.21 29.79
05/09/2008 10:45 Add 4 jxs D89409 30.00 59.79
05/12/2008 07:39 Order 2 AFC B216727 58.97 0.82
05/13/2008 11:20 Order 11 AFC K8741 0.03 0.79
05/23/2008 12:14 Add 4 SEA D90276 30.00 30.79
05/26/2008 09:26 Order 2 DDT B218596 28.92 ` 1.87
05/27/2008 08:12 Add 4 SEA D90320 40.00 41.87
06/02/2008 07:37 Order 2 DDT B219470 41.82 0.05
06/04/2008 11:08 Add 4 jxs D90852 25.00 25.05
06/04/2008 16:08 Rec Payment 7 SJW G16223 4.00 21.05
06/09/2008 08:38 Order 2 DDT B220408 20.93 0.12
06/12/2008 11:17 Add 4 gmw D91377 30.00 30.12
06/16/2008 07:19 Order 2 DDT B221335 29.94 0.18
06/30/2008 16:53 Rec Payment 10 bsp J14288 0.18 0.00
07/01/2008 12:26 Add 4 SEA D92479 20.00 20.00
07/01/2008 12:26 Rec Payment 4 SEA D92480 0.82 19.18
07/07/2008 07:15 Order 2 DDT B224103 19.08 0.10
07/07/2008 08:22 Rec Payment 10 bsp J14344 0.10 0.00
07/07/2008 12:12 Add 4 SEA D92780 20.00 20.00
07/07/2008 12:12 Rec Payment 4 SEA D92781 0.40 19.60
07/14/2008 07:57 Order 2 DDT B225051 19.60 0.00
07/15/2008 11:20 Add 4 SEA D93304 30.00 30.00
07/21/2008 07:40 Order 2 DDT B226018 29.81 0.19
07/22/2008 11:21 Add 4 jxs D93712 20.00 20.19
07/29/2008 11:49 Add 4 SEA D94081 50.00 70.19
07/30/2008 06:57 Order 2 DDT B227467 5.80 64.39
08/05/2008 11:43 Rec Payment 10 wmd J14869 2.25 62.14
08/11/2008 12:11 Add 4 jxs D94810 50.00 112.14
08/13/2008 06:41 Order 2 DDT B229125 61.21 50.93
08/14/2008 10:19 Credit 3 WLH C29939 0.91 51.84
08/14/2008 11:11 Add 7 SJW G17019 10.50 62.34
08/18/2008 11:15 Add 4 jxs D95230 20.00 82.34
08/19/2008 06:38 Order 2 DDT B229965 39.70 42.64
08/26/2008 07:33 Order 2 DDT B230832 12.89 29.75
08/26/2008 14:06 Rec Payment 10 CAM J15379 3.00 26.75
08/26/2008 14:06 Rec Payment 10 CAM J15380 0.25 26.50

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