AO 240 (Rev. 10/03)
DELAWARE {Bev. 4/05
( UNITED STATES DISTRICT COURT
. DISTRICT OF DELAWARE
I ll
Plaim f APPLICATION TO PROCEED
v. WITHOUT PREPAYMENT OF
lr 2} r3g;,gl;;;gg, FEES AND AFFIDAVIT
Defendant(s)
criss NUMBER; C)? {T}
I, ‘ 6% ‘ declare that I am the (check appropriate box)
°X° Petitioner/Plaintiff/Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees r costs de .
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings an a ‘ am F _• I re ref
sought in the complaint/petition/motion. ‘ l L I
. . . . . MAY - Ti 2008
In support of this application, I answer the following questions under penalty of per] · :
l. Are you currently incarcerated? °X°Yes ° °No (If "No" go t Ques 1
Q _ _, DIS _•_ DE rh §
If "YES" state the place of your incarceration ·.; °\\ ci • 5 `O· _ , a {{7 NJ
A C A t Sfa O I
Inmate Identification Number (Required): y
Are you employed at the institution? Do you receive any payment trom the institution?
Attach a ledger sheet from the institution of your incarceration showing at least the gast six m0nths’
transactions
2. Are you currently employed? ° ° Yes ° 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
salary or wages and pay period and the name and address of your last employer.
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 · · No
b. Rent payments, interest or dividends • • Yes • • No
c. Pensions, annuities or life insurance payments • • Yes · • No
d. Disability or workers compensation payments • • Yes • • No
e. Gifts or inheritances • • Yes • • No
f. Any other sources • • Yes • • No
Ifthe 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-00173-JJF Document 19 Filed 05/02/2008 Page 2 of 3 V
AO 240 Reverse (Rev. 10/ 03)
DELAWAREtEev. 4/05 .
4. Do you have any cash or checking or savings accounts? • • Yes · • No
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 • •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.
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 certitied 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-00173-JJF Document 19 Filed 05/02/2008 Page 3 of 3
DELANARE PSYCHIATRIC CENTER --- RESIDENT TRUST FUNDS STATEMENT --- Sooo1=PFABFUNDCL PGM·PFABFUNDCL 04-30-08 Page= 1
For Perwoo 12-01-07 tnru 05-01-08 ( 153 Days) Oor=g$m1th 11:22:17 Tenm=w1noows
Fac1?w1we$=
TRUST FUNDS B A L A N C E S
TR NO. TRANS DESCRIPTION CASH NON P/F NITHDRAN DEPOSIT ON HAND BNK/TRST BURIAL IN/OUT ENTERED INCURRED PY
——-~——»—— - ---—r - ————-—~--———-—»———· - ~—·—»——- - ——--—V-— --(DR)-- --
Name Account Room Med1ca1o # Meowcare # Admwtteo Total NAM1 Bank acc1#
STEPHENSON JOSHUA 046992 0032 - 12-19-07
Ooenwng Balances
124801 1 CKING 155362 CHK 15.00 15.00 15.00 12-27-07 12-27-07 F
CHECKS
126217.1 CKING 155461 CHK 91.72 91.72 106.72 1-11-08 1-10-08 F
CHECKS
126644.1 CASH 736796 SNK -15.00 15.00 91.72 1-15-08 1-15-08 F
SNACKS
127606 1 CASH 749509 SPD -11 00 11.00 80.72 1-28-08 1-28-08 F
SPENDING
127891.1 CKING 155544 CASH 15.00 15.00 95.72 1-28-08 1-28-08 F
CASH IN
127940.1 CASH 749512 TELE -15.00 15 00 80.72 1-29-08 1-29-08 F
TELEPHONE
128384.1 CASH 749514 TELE -15.00 15.00 65.72 2-04-08 2-04-08 F
TELEPHONE
128439.1 CASH 749515 SNK -15.00 15 00 50.72 2-05-08 2-05-08 F
SNACKS
129113.1 CASH 762774 TELE -5.72 5.72 45.00 2-12-08 2-12-08 F
TELEPHONE
129450.1 CASH 762779 TELE -1.00 1.00 44 00 2-20-08 2-20-08 F
TELEPHONE
131988.1 CKING 155958 CHK 25 00 25 00 69 00 3-31-08 3-28-08 F
CHECKS
131988 2 CKING 155958 CHK 15 00 15.00 84.00 3-31-08 3-28-08 F
CHECKS
132197 1 CASH 807961 SNE -84 00 84.00 0 00 4-02-08 4-02-08 F
SNEAKERS
132923.1 CKING 0 05 0.05 0 05 4-07-08 2-29-08 F
133254 1 CASH 824862 SPD -25.00 25.00 -24.95 4-09-08 4-09-08 F
SPENDING
133258 1 CKING 155038 CHK 45.00 45.00 20.05 4-09-08 4-09-08 F
CHECKS
133569.1 CASH 824866 TELE -20.00 20.00 0.05 4-15-08 4-15-08 F
TELEPHONE
133687 1 CASH 824869 TELE -0.05 0.05 0 00 4-18-08 4-18-08 F
TELEPHONE
CTos1ng Balances I {WIA-5 I I- 206.77 Y S I2C 5277 >—'Ai"_- -iiww—_,
206 77 '
Case 1:08-cv-00173-JJF
Document 19
Filed 05/02/2008
Page 1 of 3
Case 1:08-cv-00173-JJF
Document 19
Filed 05/02/2008
Page 2 of 3
Case 1:08-cv-00173-JJF
Document 19
Filed 05/02/2008
Page 3 of 3
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