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


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Case 1 :08-cv—00494-GIVIS Document 1 Filed 08/07/2008 Page 1 of 2
{ AO 240 (Rev. IO/03)
DELAWAR.EtRev. 4/05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
ll Xjlgj ):’f°Z { )Z|Cig{,*,.}
Plaintiff APPLICATION TO PROCEED
v. _ WITHOUT PREPAYMENT OF
3 -l~a_Je( cf gg all ·, or { FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER: O3 ` Ul Ul
I, go P ,3 ;—{ jr qi S ~, ) declare thatl am the (check appropriate box)
KB Petitioner/Plaintiff/Movant El 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 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:
l. Are you currently incarcerated? K Yes El No (If "No" go to Question 2)
If "YES" state the place of your incarceration lll? l l , ‘
Inmate Identification Number (Required): j i?;T_"§.,.J§‘ ll Ls Qt`!
Are you employed at the institution? /cl(l Do you receive any payment from the institution? Q Q f
Attach a ledger sheet Qorn the institution of your incarceration showing at least the past six months ’
transactions
2. Are you currently employed? E-I Yes E/ 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. N
¤=¤ Urn
b. If the answer is "NO" state the date of your last employment, the amount of your
salary or wages and pay period and the name and address of your last employer.
s Q., MJ
3. In the past l2 twelve months have you received any money from any of the following sourcgi?
"U F·‘¢:.o»~»
x eg; Fi
a. Business, profession or other self-employment Ei Yes .H/ Nm
b. Rent payments, interest or dividends E1 Yes .12/ No.
c. Pensions, annuities or life insurance payments El Yes JE! NUJ ii
d. Disability or workers compensation payments El Yes 2/ No
e. Gifts or inheritances Et" Yes Ei No
f. Any other sources E' Yes B?""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—00494-GIVIS Document 1 Filed 08/07/2008 Page 2 of 2 A
Jes
AO 240 Reverse (Rev. IO/03)
DELAWARElRcv. 4/D5!
MI i A U_;O(ip( ,?:»·’ u` { gel I gy 5 Q Y__,,&U ,,%,,1;;,, C. Siu H"_$éZ¤ »*·¤ 9 I. gl/'}S 5:%) EB
4. D0 you have any cash or checking or savings accounts? El Yes j2(No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
valuable property? _\
II! Yes No
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.
I declare under penalty of perjury that the above infomation is true and correct.
. l
Q/7/of _ 4/— . . mmf
D TE 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 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—00494-G|\/IS Document 1-2 Filed 08/07/2008 Page 1 of 2
STATE or DELAWARE
DEPARTMENT or CORRECTION
BUREAU or ADULT CORRECTION
HOWARD R. YoUNG coRREcT1oNAL INSTITUTION
1>.o. Box 9279
WILMINGTON DE 19801
(BUSINESS ADDRESS)
Memorandum
To: Daniel Shaw, SBI # 176206, 2S, 13
From: Business Office
Date: July 16, 2008
Re: Response to your letter.
Mr. Shaw,
Here is a copy of your 6 month history and balance.

Case 1 :08—cv—00494-GIVIS Document 1-2 Filed 08/07/2008 Page 2 of 2
RESIDENT HISTORY REPORT Page 1 0f 1
HRYCI '.4_
07/16/0813:41 .
ST 006 / OPR JNM :13 * ‘
SBI : 176206
Resident Name : SHAW, DANIEL
Time Frame : O2/01/2008 10:46 ~ 07/16/2008 13:41
Date Time Type ST OPR Receipt # Amount Balance
02/04/2008 06:45 Order 2 AFC B203296 17.33 340.79
02/08/2008 09:30 Order 2 DDT B204133 8.01 332.78
02/14/2008 09:43 Add 6 JNM F35454 15.00 347.78
02/15/2008 15:19 Add 7 SJW G14373 14.40 362.18
02/19/2008 06:19 Order 2 DDT B205639 11.13 351.05
02/26/2008 07:34 Order 2 AFC B206927 7.88 343.17
03/04/2008 07:43 Order 2 AFC B207670 7.82 335.35
03/06/2008 12:58 Order 3 WLH C26207 0.79 334.56
03/07/2008 11:36 Add 4 J D85702 20.00 354.56
.03/11/2008 06:47 Order 2 DDT B208749 5.26 349.30
03/17/2008 13:05 Order 2 DDT B209853 6.21 343.09
03/20/2008 13:10 Rec Payment: 10 bsp J1280O 0.25 342.84
03/21/2008 11:45 Add 4 J D86608 25.00 367.84
03/25/2008 09:50 Order 2 DDT B210547 6.28 361.56
O4/01/2008 08:59 Order 2 DDT B211511 3.93 357.63
04/08/2008 07:05 Order 2 DDT B212420 7.10 350.53
04/09/2008 12:06 Add 4 gmw D87695 20.00 370.53
04/11/2008 11:35 Add 4 gmw D87811 10.00 380.53
04/15/2008 09:18 Order 2 DDT B213504 11.57 368.96
O4/22/2008 07:43 Order 2 AFC B214382 7.49 361.47
04/29/2008 09:11 Order 2 DDT B215294 8.42 353.05
05/06/2008 07:24 order 2 DDT B216180 8.75% 344.30
05/09/2008 10:00 Credit`? 3 wpr C27703 05/12/2008 07:03 Order 2 AFC B216679 11.88 341.17
05/15/2008 12:26 Rec Payment 10 bep J13872 0.23 340.94
05/19/2008 06:52 Order 2 DDT B217578 7.33 333.61
05/26/2008 08:44 Order' 2 DDT B218514 ?10.92 322.69
05/27/2008 13:20 Credit5> 3 WLH C28258 <\ 4.20/> 326.89
06/02/2008 06:32 Order 2 DDT B219326 11.18 315.71
06/09/2008 09:26 Order 2 DDT B220469 6.00 309.71
06/16/2008 07:45 Order 2 DDT B221386 6.17 303.54
06/23/2008 07:43 Order 2 DDT B222315 9.59 293.95
06/30/2008 10:56 Order 2 DDT B223213 6.75 287.20
07/07/2008 07:26 Rec Payment 10 bsp J14294 0.10 287.10
07/07/2008 08:29 Order 2 DDT B224151 9.72 277.38
07/07/2008 13:31 Rec Payment 10 bsp J14377 0.46 276.92
07/14/2008 08:49 Order 2 DDT B225071 (37.71 4 269.21
07/15/2008 08:38 Credit \> 3 WLH C29385 6.25;> 275.46
07/15/2008 08:38 Order 3 WLH C29386 3.25 272.21
07/15/2008 08:41 Order 3 WLH C29387 5.00 267.21

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