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

·;_ 7 . Case 1 :08-cv—OO161-SLR Document 1 Filed O3/24/2008 Page 1 of 2 .
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DELAWARE 40151 ` .
_ \ D K'- UNITED STATES DISTRICT COURT
?`\G\Nl" DISTRICT OF DELAWARE
y Plaintiff APPLICATION TO PROCEED
p v. WITHOUT PREPAYMENT OF
FEES AND AF FIDAVIT
Defendant(s) .
CASE NUMBER: ..
———e 0 s 1 6 I -
I, J-;.g;g ~ /0c /3ZwJ declare that I am the (check appropriate box)
°A Petitioner.lPlaintiff·’lvIovant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepa ree -1 .1 9 11 irr. ._t(. , ,.___,. 1
28 USC §l9l5, Ideclare that I am unable to pay the costs of these proceedings andt t I am enti?%t@tl§ wd _
sought in the complainulpetitioxifmotion. i‘ ‘ e‘ ‘ s “ ‘*‘‘ · ‘‘
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nits P; s rsstl ;
1 In support of this application, I answer the folloyng questions under penalty of perj il l
{ ra. .r2,,,,.m,m_,1,___ _ 3
`l. Are you currently incarcerated? ° Yes ° °No (If "No" go to
If "YES" state the place of your incarceration [1- rg - {Z; Cl Z 1 Sfm O rm;
Inmate Identification Number (Required): JPEKWLI ,2
Are you employed at thelinstitution? ltd Do you receive any payment from the institution? ${65 l
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast six months '
transactions ·/
2. Are you currently employed? l ° Yes A ° 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 Vi No
e. Gifts or inheritances " • · Yes •/{ No
f. Any other sources • · Yes •[ No
If the answer to any ofthe above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.

·» ~J-- l· Case 1 :08-cv-00161-SLR Document 1 Filed O3/24/2008 Page 2 of 2 .. s
AO 240 Reverse [Rev. `l.U/ U3}
DELAWARE Env. 4505] V .
l 4. Do you have any cash or checking or savings accounts? • · Yes ·6lo
If "Yes" state the total amount S ‘
5. Do you own any real estate, stocks, bonds, securities, other financial i.nsI:m.1ments, automobiles or other
valuable property? ‘
• • Yes K 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.
x $l—xr@§éOl§ X gra · .- . ~ . r, p
AT - SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall suhmit an afiidavit
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 ins_titutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certiiied
statement of each account.

" .| ~ ; Case 1:08-cv-00161-SLR Document 1-2 Filed O3/24/2008 Page 1 of 2
RESIDENT HISTORY REPORT PESE l Of 2
HRYCI
U3/11/08 15:25
ST 010 / OPR JNM
SBI : 163732
Resident Name : PERSON, JAMES
Time Frame : 09/01/2007 13:36 - 03/11/2008 15:25
Date Time Type ST OPR Receipt # Amount Balance
09/07/2007 13:00 Order 3 AFC C22111 20.90 488.80
09/07/2007 14:19 Add 10 bsp J11918 35.00 523.80
09/11/2007 13:10 Order 3 AFC C22186 5.17 518.63
09/12/2007 13:21 Order 3 AFC C22219 2.10 516.53
09/13/2007 14:05 Order 3 AFC C22246 3.20 513.33
09/14/2007 11:30 Order 3 AFC C22268 5.07 508.26
09/18/2007 11:51 Add 4 gmw D75818 50.00 558.26
09/19/2007 14:30 Order 11 DDT K5390 0.68 557.58
09/21/2007 11:30 Order 3 AFC C22494 10.65 546.93
09/21/2007 11:36 Order 3 AFC C22496 1.16 545.77
09/21/2007 13:48 Order 3 WLH C22500 2.45 543.32
09/25/2007 13:44 Order 3 AFC C22618 7.49 535.83
09/28/2007 14:03 Order 3 WLH C22790 6.10 529.73
10/03/2007 14:27 Order 11 WLH K5601 7.66 522.07
10/05/2007 12:38 Order 11 AFC K5654 12.81 509.26
10/05/2007 12:50 Order 11 AFC K5655 2.26 507.00
10/10/2007 14:24 Add 7 SJW G12805 35.00 542.00
10/11/2007 13:31 Order 3 AFC C23091 0.83 541.17
10/12/2007 11:05 Order 3 AFC C23100 24.56 516.61
10/12/2007 12:19 Order 3 AFC C23101 1.68 514.93
10/12/2007 12:20 Order 3 AFC C23102 0.68 514.25
10/12/2007 12:21 Credit 3 AFC C23103 1.68 515.93
10/19/2007 14:47 Order 11 AFC K5785 22.20 493.73
10/22/2007 14:36 Order 11 AFC K5794 1.95 491.78
10/23/2007 08:24 Add 8 bsf H34388 25.00 516.78
10/26/2007 14:07 Order 3 WLH C23289 13.61 503.17
10/29/2007 14:26 Order 11 AFC K5858 0.68 502.49
10/31/2007 12:13 Order 11 AFC K5894 15.63 486.86
10/31/2007 12:14 Order 11 AFC K5895 2.60 484.26
11/01/2007 09:39 Add 8 bef H34574 60.00 544.26
11/02/2007 13:30 Order 11 AFC K5986 3.89 540.37
11/07/2007 13:33 Add 10 bsp J12444 35.00 575.37
11/07/2007 13:53 Order 3 WLH C23485 7.84 567.53
11/08/2007 08:59 Add 8 bef H34767 40.00 607.53
11/09/2007 13:40 Order 3 WLH C23536 3.76 603.77
11/15/2007 12:44 Order 11 AFC K6148 0.50 603.27
11/16/2007 11:23 Order 3 AFC C23639 11.57 591.70
11/16/2007 11:30 Order 3 AFC C23641 2.40 589.30
11/21/2007 12:59 Order 3 AFC C23765 2.25 587.05
11/23/2007 11:28 Order 11 AFC K6261 10.34 576.71
11/23/2007 11:30 Order 11 AFC K6262 1.40 575.31
11/28/2007 13:56 Order 11 AFC K6300 7.62 567.69
11/30/2007 13:34 Order 3 AFC C23981 9.83 557.86
11/30/2007 13:36 Order 3 AFC C23982 2.52 555.34
12/03/2007 08:27 Order 3 AFC C23985 1.90 553.44
12/03/2007 13:42 Order 3 AFC C24012 1.68 551.76
12/03/2007 13:56 Order 3 AFC C24013 0.68 551.08
12/04/2007 13:38 Order 3 AFC C24035 3.96 547.12
12/06/2007 13:17 Order 3 AFC C24133 5.07 542.05
12/07/2007 11:56 Add 7 SJW G13288 35.00 577.05
12/07/2007 12:12 Order 3 AFC C24159 14.24 562.81
12/07/2007 12:14 Order 3 AFC C24161 2.13 560.68
12/14/2007 09:50 Order 2 DDT B196682 19.61 541.07
12/18/2007 12:38 Order 3 AFC C24407 2.13 538.94
12/18/2007 13:32 Order 3 AFC C24415 1.25 537.69
12/20/2007 13:22 Order 3 WLH C24447 1.40 536.29
12/20/2007 13:30 Order 3 WLH C24450 1.40 534.89
12/21/2007 13:54 Order 3 WLH C24464 3.76 531.13

. A; · Case 1:08-cv-00161-SLR Document 1-2 Fnled O3/24/2008 Page 2 of 2
RESIDENT HISTORY REPORT PAGE 2 of 2
HRYCI
O3/11/OB 15:25
sw 010 / 01:11 nm
SBI : 163732
Resident Name : PERSON, JAMES
Time Frame : 09/01/2007 13:36 - 03/11/2008 15:25
Date Time Type ST OPR Receipt: # Amount Balance
12/21/2007 13:54 Order 3 WLH C24465 1.30 529.83
12/24/2007 14:36 Order 11 WLH K6637 4.80 525.03
12/24/2007 14:42 Order 11 WLH K6638 2.52 522.51
12/26/2007 13:26 Add 4 SEA DB1607 40.00 562.51
12/27/2007 14:39 Order 11 WLH K6699 5.16 557.35
12/31/2007 14:49 Order 3 WLH C24698 7.29 550.06
12/31/2007 14:49 Credit 3 WLH C24699 7.29 557.35
01/02/2008 14:17 Order 3 WLH C24738 4.74 552.61
01/03/2008 13:59 Order 3 AFC C24778 2.11 550.50
01/05/2000 13:21 Order 3 AFC C24845 7.76 542.74
01/08/2008 13:12 Order 11 AFC K6878 1.10 541.64
01/09/2008 14:05 Order 11 AFC K6910 5.53 536.11
01/14/2008 14:07 Add 7 SJW G13690 35.00 571.11
01/15/2008 13:38 Order 3 WLH C25156 6.76 564.35
01/17/2008 14:06 Order 3 AFC C25206 5.58 558.77
01/21/2008 14:20 Order 11 AFC K7085 5.90 552.87
01/22/2008 13:57 Order 11 AFC K7092 8.20 544.67
01/23/2008 13:50 Order 11 AFC K7110 18.30 526.37
01/23/2008 13:51 Credit 11 AFC K7111 18.30 544.67
01/24/2008 11:34 Add 4 gmw D83115 25.00 569.67
01/25/2008 12:01 Order 3 WLH C25352 6.82 562.85
01/25/2008 13:45 Order 3 WLH C25354 14.26 548.59
01/25/2008 13:48 Credit 3 WLH C25355 14.26 562.85
02/01/2008 13:33 Order 3 WLH C25507 26.13 536.72
02/01/2008 13:35 Credit 3 WLH C25508 26.13 562.85
02/04/2008 14:31 Order 11 AFC K7206 0.84 562.01
02/04/2000 14:32 Order 11 AFC K7208 2.49 559.52
02/08/2008 13:46 Order 11 AFC K7272 2.32 557.20
02/08/2008 14:30 Order 11 AFC K7273 0.68 556.52
02/11/2008 14:44 Order 3 WLH C25664 4.20 552.32
02/11/2008 14:45 Order 3 WLH C25665 1.26 551.06
02/14/2008 14:56 Add 7 SJW G14125 35.00 586.06
02/15/2008 13:18 Order 3 WLH C25822 5.33 580.73
02/29/2008 10:50 Order 3 AFC C26090 8.53 572.20
02/29/2008 11:23 Order 3 AFC C26094 3.27 568.93
03/03/2008 14:00 Order 11 AFC K7466 2.95 565.98
03/04/2008 08:34 Add 8 bef H37474 50.00 615.98
03/04/2008 14:39 Order 11 AFC K7473 0.34 615.64
03/10/2008 15:42 Add 7 SJW G14601 35.00 650.64

Case 1:08-cv-00161-SLR

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