we 140 {Rev, iu/01)
UNITED STATES DISTRICT COURT
District of Qfig; H Q
I APPLICATION TO PROCEED A
Plaintiff - g WITHOUT PREPAYMENT OF _ .
_ V _ FEES AND AFFIDAVIT
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A 0a~, E ae
CASE NUMBER; 3 7 2:%
Defendant LJ
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H . 1 5 . E,;s°·§.5
I, ‘ if declare that I am the (check appropriate be§ gb
CI petitioner/plaintiff/movant CI ether Q-?
-·-
in the above-entitled preceeding; that in support of my request to proceed without prepayment of fees orwosts H ii
under 28 USC § 1915 I declare thatI am unable to pay the costs of these proceedings and thatI am entitled to the relief I
sought inthe complaint/petition/motion. ‘
In support of this application, I answer the following questions under penalty of perjury: .
l. Are you currently incarcerated? EZI Yes L [I No (If “No," go to Part 2)
If “Yes," state the place of your incarceration ig ] ; E gf [ QUE; ibm;] i ( QM if);
I Are you employed at the institution? M Lg 2 Do you receive any payment from the institution? ( [
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
transactions.
_ 2. Are you currently employed? n EI Yes `M
a. If 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. If the answer is “No," state the date of your last employment, the amount ofyqur take-home salary or wages I
and pay period and the name and address of your last employer. WL www
[VL HYIE, {IIC}/l€If'l ·7—Li Ctr/CiS Ce.!/L i/VDUIC I
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 EI Yes El No
b. Rent payments, interest or dividends El Yes El No ,_
c. Pensions, annuities or life insurance payments EI Yes lZLN{ g
d. Disability or workers compensation payments EI Yes lZLl>
f. Any other sources ` lj Yes |1I,No"
If the answer to any of the 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-00137-Gl\/IS Document 1 Filed 03/07/2008 Page 2 of 3
AO 240 Reverse (Rev ., 10/03)
`4. D0 you have any cash or checking or savings accounts? ` El Yes $% A
If "Yes," state the total amount. `
5. Do you own any real estate, stocks, bonds, securiti , ther financial instruments, automobiles or any other
thing of value? Cl Yes @$1%,0 y
If "Yes," describe the property and state its value. A
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. 0 In Q
I declare under penalty of perjury that the above information is true and correct.
Date ; Siglaature of Applicant
NOTICE TO PRISONER: A Prisoner seeking to proceedwithout 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 f
multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each
account.
. ° n Case 1:08-cv-00137-Gl\/IS Document 1 Filed 03/07/2008 Page 3 of 3 g
%AO 240A (Rev. ll/03) i
· UNITED STATES DISTRICT COURT
District of
` n ORDERAON APPLICATION E
Plaintiff TO PROCEED WITHOUT
. V PREPAYMENT OF FEES D
I CASE NUMBER:
Defendant
O Having considered} the application to proceed without prepayment of fees under 28 USC §l915;
IT IS ORDERED that the application is: g
I] GRANTED. _
I] The clerk is directed to tile the complaint.
I] 1T 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.
I] DENIED, for the following reasons: .
ENTER this day of , .
Signature of Judge
Name and Title of Judge
Case 1:08-cv-OO137—GI\/IS Document 1-2 Filed O3/07/2008 Page 1 0f 1
DELA WARE C ORRE C T I ONAL CENTER
SUPPORT SER VI CES OFFICE
MEMORANDUM \
‘——-r"°-2 " .
To; I Ngw HM QQQ/L, sE1#.- NQ IDX
FROM: Stacy Shane, Support Services Secretary
RE: 6 Months Account Statement
DATE.- {MQ; gi lll 5 gpg
tached are copies of your inmate accountstatementforht months of
gg I IQRBYF) to tf_ ·_;-t;;.. ,1 1-:
T he following indicates the average daily balances.
MONTH AVERAGE DAILYBALANCE
%S& ___.__%*
E ·;`.? ’ A rs le) ill}
D2. 0*0
Average daily balances/6 months: QJ
Attachments
CC: F `le
jfgdé Algae ta/W
. i _3/g)@g/ 3/we
Case 1:08-cv-00137-GMS
Document 1
Filed 03/07/2008
Page 1 of 3
Case 1:08-cv-00137-GMS
Document 1
Filed 03/07/2008
Page 2 of 3
Case 1:08-cv-00137-GMS
Document 1
Filed 03/07/2008
Page 3 of 3
Case 1:08-cv-00137-GMS
Document 1-2
Filed 03/07/2008
Page 1 of 1
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