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

Case 1 :08-cv·OO157-JJF Document 5 Filed O4/08/2008 Page 1 of 2
base 1:O8—ov-OG1b7-JJF Document 4 Filed 03/2 H2008 Page 3 , 4 ;—-—...r»t..a,2T..._,_5X,.,,.ff
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UNITED STATES DISTRICT COURT D&i§Pt·tStaict E6[i§E“"“‘“
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DISTRICT OF DELAWARE · '"““`""*‘*£~§——¥i1#¥’—fi41h...a..,,_
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Plaintiff APPLICATION TO P OCEED
- v. * ~ , , ` - - _ WITHOUT PREPAYMENT OF
IW), tmikra L L al i:t•:.ifr.»¤’> a/is/ia altar
L O » Y . · , . ph UM A FEES AND AFFIDAVIT
1 Defendant(s)
CASE NUMBER: OS- l 57-JJF
lgg)],i_§_,iQQyi?OfL(>;;g_gm5·¤ E M r_—;·?,j gi, declare that I am the (check appropriate box)
V l’etitioner!Plaintiff/Movant El Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
QS l’St` §I9l 5, l declare that l am unable to pay the costs of these proceedings and that 1 am entitled to the relief
sought in the compiaiiit/petitioiifmotion.
ln support of this application, l answer the fol questions under penalty of perjury;
1. Are you currently incarcerated? Yes D No (If "No" go to Question 2)
ll"‘YliS" state the place ofyour incarceration , . ., , _ _ » .5 Y- ` · u gu
inmate Identification Number (Required): O p
Mc you employed at the institution? Ml) Do you receive any payment from the institution? MQ
.=lmrclr rr led nar s/rear mm the insritutirm 0 our inc rcemtion detailin all zrrmsrrcrivns aver the asl
six iirrmrlrs.
2 .-\re you currently employed? E Yes No
n. ifthe answer is "YES" state the amount ofyour take-home salary or wages and pay period
and give the name and address ofyour employer.
li, if the answer is "NO" state the date of your last employment, the amount ofyour take—home
salary or wages and pay period and the name and address of your last employer.
at l a i at
3 ln the past I2 twelve months have you received any money from any ofthe following sources?
n. Business, profession or other self-employment D Yes <§No
li. Rent payments, interest or dividends in Yes Q//No
c. Pensions, annuities or life insurance payments El Yes No
tl. Disability or workers compensation payments D Yes , 2QNo
c. Gifts or inheritances D Yes fd
i] Any other sources D Yes No
lfthc answer to any ofthe above is "YES" describe each source ofmoney and state the amount
rcucivecl AND what you expect you will continue to receive.

Case_1 :08-cv-001,57-JJF Document 5 Filed O4/08/2008 Page 2 of 2
Case ‘l;i38-cv—0Gi57—JJF Document 4 Filed O3i'27!2UO8 Page 4 ot 4
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cl. llo you have any cash or checking or savings accounts? El Yes Ai
ll"'Yes" state the total amount S
5. lilo you own any real estate, stocks, bonds, securities, other financial instruments, automobile r other
talunble property? E/0
D Yes No
ll"'Yes" describe the property and state its value.
ti. list the persons who are dependent on you for support, state your relationship to each person and
intlicnte how much you contribute to their support, OR state NONE if applicable.
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oiiixta lie
l declare under penalty of perjury that the above information is true and correct.
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l)A“l"E I SIGNATU EOF AP LICANT
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N()'l`lB TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating nil assets. in addition, n prisoner must attach a statement certified by the appropriate institutional
ot'lit·crsl1nwing all receipts, expenditures, and balances during the Inst six months in your institutional accounts.
li' you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
stntctncnt ol` each account. t

Case 1:08-cv—OO157-JJF Document 5-2 Fnled O4/08/2008 Page 1 of 1
— (D i§ eo \57 J5 F
RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
D1/31/08 09:42
ST 007 / GPR SJW
S5I : 240523
Resident Name : OWENS, USHANGO
Time Frame : 08/01/2007 22:25 — 01/31/2008 09:42
Date Time Type ST GPR Receipt # Amount Balance
05/03/2007 09:45 Credit 11 WLH K-1959 15.41 19.72
05/05/2007 13:44 Order 2 WLH 5179147 13 .99 5.73
08/13/2007 10:40 Order 2 DDT 5150065 5.68 0 .05
08/27/2007 05:55 Add 4 gmw D74482 250.00 250 .05
08/27/2007 13:39 Order 2 DDT 5151977 58.53 201.42
05/25/2007 13:55 Credit _ 3 WLH C2155B 10.34 211 .76
05/31/2007 10:27 Withdrawal 5 SJW F31444 50.00 151.76
05/31/2007 10:33 Withdrawal 5 SJW F'31447 100.00` 61 .75
05/31/2007 13:41 Rec Payment 10 bsp J11759 1.50 60.25
09/03/2007 10:44 Order 2 WLH 5152597 45.12 14 .14
09/05/2007 13:25 Order 3 AFC C22025 2.20 11.94
09/10/2007 11:05 Order 2 DDT 5183578 11.85 0.09
09/21/2007 11:45 Add 4 J D75029 100.00 100 .09
09/25/2007 05:34 Order 2 DDT BL55805 59.44 40.65 '
10/01/2007 05:55 Add 4 grnw D76499 ' 24 .00 54 .55
10/01/2007 11:15 Order 2 DDT 5185705 30.51 34 .14
10/02/2007 10:41 Credit 3 AFC C22857 1.10 ` 35 .24
10/02/2007 10:42 Order 3 AFC C2286B 15.41 19.53
10/02/2007 10:44 Credit 3 AFC C22B69 12.25 32 .05
10/04/2007 13:21 Rec Payment 10 bsp J12254 2.00 30.05
10/04/2007 14:57 Withdrawal 5 SJW F32276 16.00 14 .05
10/05/2007 09:43 Order 2 DDT 5157577 14 .05 0 .02
10/29/2007 09:44 Add 4 gmw D75024 40.00 40 .02
10/29/2007 10:22 Order . 2 DDT 5190459 5.10 33.92
10/29/2007 13:49 Rec Payment 10 hep J12373 17.25 16.57
10/30/2007 11:27 Credit 3 WLH C23314 2.00 15.67
10/31/2007 11:56 Rec Payment 10 bsp J12391 10.45 5.22
11/05/2007 09:45 Order 2 DDT 5191292 3.53 4.59
11/07/2007 11:45 Rec Payment. 10 bsp J12422 4.00 0.59
11/12/2007 09:02 Order 2 AFC 5192250 0.59 0 .00
12/14/2007 11:29 Add 4 J D80507 100.00 100.00
12/15/2007 09:55 Order 2 AFC 5197353 44 .99 55 .01
12/21/2007 13:11 Withdrawal 6 SJW F34075 50.00 5.01
12/31/2007 14:05 Withdrawal 6 SJW F34153 2.64 2 .37
01/02/2005 06:19 Order 2 DDT 5199259 2.36 0 .01

Case 1:08-cv-00157-JJF

Document 5

Filed 04/08/2008

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Case 1:08-cv-00157-JJF

Document 5

Filed 04/08/2008

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Case 1:08-cv-00157-JJF

Document 5-2

Filed 04/08/2008

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