REAO 240 (Rev. 10/03) `
T RECENED-DCC
UNITED STATES DISTRICT COURT
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SUPPORT SERVICES MANAGER I
Jaime. Q..$wte·\ APPLICATION TO PROCEED
T _ Plaintiff WITHOUTPREPAYMENT 3* ` ‘``‘‘P i‘"’i“‘ '`i`` '-'i"ii''`' J
4 V FEES AND AFFIDAVIT TEE T T T T T T
" Y if 2 gi ititlt li *4 20%%
n Arcs; OQ Qsaxeciapa CASE NUMBER BFQ ’1¤<>*v ,__A _,,_ T. .,._ T TT. T.T. ..`,.
U.S.Dl’STEtlG'l’ COURT ;
I D€f`i’“d““t TTT.T T TT.T T T TT,TT i r .,TTT T TTTTTTT.
I, ,§Qtm,.._ g, gy mg; declare thatI am the (check appropriate box)
ll? petitioner/plaintiff/movant lj other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC § 1915 I declare thatl 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: n T
l. TAre you currently incarcerated? LZ] Yes lj No (lf "No," go to Part 2) _ I
_ If "Yes," state the place of your incarceration QE; Q, M H (3_Q.££¤ {QS, may gg Egg; E I
Are you employed at the institution? A/Q Do you receive any payment from the institution? gg?
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
transactions.
2. Are you_currently employed? lj Yes E|'No _ I
a. lf the answer is "Yes,†state the amount of your take-home salary or wages and pay period and give the
name and address of your employer.
_ b. lf the answer is "No," state the date of your last employment, the amount of your tal
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 lj Yes El No y
b. Rent payments, interest or dividends lj Yes El No
c. Pensions, annuities or life insurance payments El Yes Q’No
d. Disability or workers compensation payments [I Yes EZYNo
e. Gifts or inheritances U Yes Q"No
f. Any other sources lj Yes Q/No
If the answer to any ofthe above is "Yes," describe, on the following page, each source of money and state the
amount received and what you expect you will continue to receive.
` Case 1 :08-cv—OO152-SLR Document 1 Filed O3/14/2008 Page 2 of 3
AO 240 Reverse (Rev. [M13) l ,
4. D0 you have any cash or checking 0r savings accounts? El Yes ` Q’No
lf "Yes,†state the total amount. I g
5. D0 you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
thing of value? El Yes Q’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. N/A
I declare under penalty of perjury that the above information is true and correct.
Date J Signature of Applicant
NOTICE 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 r
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—OO152-SLR Document 1 Filed O3/14/2008 Page 3 of 3
aao ma (Rev. umn) ;
A I UNITED STATES DISTRICT COURT
§j¤,§g{3=s§C.§£» ;_,~ §».;jg@\ C Q; mj; District of I); jg!} my;
hmm (_ B l QU ORDER ON APPLICATION
Plaintiff A TO PROCEED WITHOUT O g =·- I 5 2
` V PREPAYMENT OF FEES I
5* CA L Og? BC CASE NUMBER: 55c¤.’9O*°`7
Defendant \ QWCNL
Having considered the application to proceed without prepayment of fees under 28 USC §l9l5;
IT IS ORDERED that the application is:
III GRANTED.
III The clerk is directed to file the complaint. A
El IT IS FURTHER ORDERED that the clerk issue summons and the United States marshal serve a
copy of the complaint, summons and this order upon the defendant(s) as directed by the plaintiff.
All costs of service shall be advanced by the United States.
El DENIED, for the following reasons:
ENTER this day of . g , .
Signature of Judge
Name and Title of Judge -
Case 1:08-cv-00152-SLR Document 1-2 Filed O3/14/2008 Page 1 of 1
DELAWARE CORRE CT IONAL CENTER
SUPPORT SER VICES OFFICE
MEMORANDUM
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To.- ( }iO.[ @ i if KQ; seat.- [ Q; gg gg
FROM: tacy Shane, Support Services Secretary ___p _e_p __pcc_.p S ..e.1. .. ...1 e.=.. -.----1
RE: 6Months Account Statement · l 2
DATE {gil 2 Z ;E/ t1t2R1@2@@&·%
ctt
4 ._ ached CIFIQ CO l€S ofyour lnmdf CICCOLLIU Sl°(1I€i7’tE?I’ll°_]rO}†Elle! l1Il’LS Of
A j.bL,1.4.11e L 1 tv
The following indicates the average daily balances.
MONTH AVERAGE DAILYBALANCE
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Average daily balances/6 months: · Il
Attachments
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)&tw% A/7/ti
E/t/W
Case 1:08-cv-00152-SLR
Document 1
Filed 03/14/2008
Page 1 of 3
Case 1:08-cv-00152-SLR
Document 1
Filed 03/14/2008
Page 2 of 3
Case 1:08-cv-00152-SLR
Document 1
Filed 03/14/2008
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Case 1:08-cv-00152-SLR
Document 1-2
Filed 03/14/2008
Page 1 of 1
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