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

Case 1 :08-cv—00507-GIVIS Document 1 Filed 08/12/2008 Page 1 of 4
AO 240 (Rev. I0/03)
DELAWARE (Rev. 4/05)
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UNITED STATES DISTRICT COURT } · It " t ,; e ; yy
DISTRICT OF DELAWARE, J I `
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Plaintiff APPLICATION TO PROCEED
S V. WITHOUT PREPAYMENT OF /4
A SS ei 'é.€5 FEES AND AFFIDAVIT
Defendant(s) rv A __?
CASE NUMBER: *
I, gin`; g g S (rx; ‘{’ to declare that I am the (check appropriate box)
@ Petitioner/Plaintiff/Movant ° ° Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that [ am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following quest` • - · ¤ a : penalty of perjury:
l. Are you currently incarcerated? ° Yes (If "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet from the institution of your incarceration showing at least the gast six months '
transactions G
2. Are you currently employed? ° ° Yes @ "`
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
salary or wag§ and pay period and the name and address of your last employer. FA
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3. In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employment • • Yes @
b. Rent payments, interest or dividends • • Yes
c. Pensions, annuities or life insurance payments • · Yes
d. .\ Disability or workers compensation payments • • Yes jig
e. Gifts or inheritances • • Yes @
f. Any other sources iv [@0,, U Q ’ ' N0
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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.
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Case 1 :08-cv—00507-GIVIS Document 1 Filed 08/12/2008 Page 2 of 4
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AO 240 Reverse (Rev. 10/O3)
DELAWARE Rev. 4{OS)
4. D0 you have any cash or checking or savings accounts? • •No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? dl /2 WO pug /0 @ · ·NO
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If "Yes" describe the property and state its value. /V07-ET 3 400 _ OD /7**0*57%
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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.
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I declare under penalty of perjury that the abo; information is true aniorrect.
l i2TE ( SIGNA URE 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
officer 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—00507-GIVIS Document 1 Filed 08/12/2008 Page 3 of 4
Page: 1 Document Name: untitled
ECHO DELAWARE DEPARTMENT OF LABOR 08/04/2008
_ ` UNEMPLOYMENT INSURANCE CLAIM HISTORY
I PAYMENT HISTORY
SSN: — 6071
NAME: D SMITH
CLAIM DATE: 03/30/2008
FC CHK DATE CHK NUM CWED WBA EARNGS ADJ OPY CHS FIT NET BALA ML
-10 08/04/08 7676004 08-02 330 330 33 297 2640
10 07/28/08 7664001 07-26 330 330 33 297 2970
10 07/21/08 7652350 07-19 330 330 33 297 3300
10 07/14/08 7642143 07-12 330 330 33 297 3630
10 07/07/08 7632911 07-05 330 330 33 297 3960
10 06/30/08 7624055 06-28 330 330 33 297 4290
10 06/23/08 7615897 06-21 330 330 33 297 4620
10 06/18/08 7614643 06-14 330 330 33 297 4950
10 06/09/08 7600327 06-07 330 330 33 297 5280
10 06/02/08 7592951 05-31 330 330 33 297 5610
10 05/27/08 7584978 05-24 330 330 33 297 5940
10 05/19/08 7576362 05-17 330 330 33 297 6270
10 05/12/08 7568790 05-10 330 330 33 297 6600
10 05/05/08 7561176 05-03 330 330 33 297 693
F2=NXT F4=EXT F6-PND F8=WAG F9=HST F10=DIS F11=NT ECHOMAP
ECHOINQ
‘&t€: 8/4/2008 Time: 1:27:46 PM

Case 1 :08-cv—00507-GIVIS Document 1 Filed 08/12/2008 Page 4 of 4
Page: 1 Document Name: untitled
ECHO DELAWARE DEPARTMENT OF LABOR 08/04/2008
_ ) UNEMPLOYMENT INSURANCE CLAIM HISTORY
PAYMENT HISTORY
ssm; 1 6071
NAME: D SMITH
CLAIM DATE: 03/30/2008
FC CHK DATE CHK NUM CWED WBA EARNGS ADJ OPY CHS FIT NET BALA ML
10 04/28/08 7552596 04-26 330 330 33 297 7260
10 04/21/08 7544733 04-19 330 330 33 297 7590
10 04/14/08 7536605 04-12 330 330 33 297 7920
L10 04/07/08 7528233 04-05 330 330 33 297 8250 ;
OLD CLAIM 03/25/2007
10 03/31/08 7519150 03-29 8 330 330 330 685
10 03/24/08 7510483 03-22 330 330 330 1015
10 03/17/08 7501752 03-15 330 330 330 1345
10 03/10/08 7492420 03-08 330 330 330 1675
10 03/04/08 7488573 03-01 330 330 330 2005
10 02/28/08 7480756 02-23 330 330 330 2335
10 02/28/08 7480756 02-16 330 330 330 2665
10 02/28/08 7480756 02-09 330 330 330 2995
10 02/28/08 7480755 02-02 330 330 330 3325
F2=NXT F3=PRV F4=EXT F6-PND F8=WAG F9=HST F10=DIS F11=NT ECHOMAP
ECHOINQ
D&t€: 8/4/2008 Time: 1:27:51 PM

Case 1:08-cv-00507-GMS

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