I ‘ ` a AO1e0(Rzv. 10/O3)
DELAWARE gev. 4[D5
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
tu: d*l.eeu,iZ §`e.$¤td [Ca?
: ` s·· UCC 1--».’;%‘~·P’i`it i·-3<>‘in i.. tt>3.£»
y Ptaimrr APPLICATION TO PROCEED
v., . ~ VVITHOUT PREPAYMENT OF
lbernlaru i; al Ftolie--- Mikie .
. . v at msaatewji FEES AND AF FIDAVIT
L-tink ¤ Defendant(s) . __ _ _ {
I _ casartnmsaa; D$~ i3'-|· J.)?
HE C P to ` ‘ Ina: pw ssa
I, { . " ·-lilit. R ml) mi 9 (5 hw! Sk" ‘\mdia%:1are that I ani the (check appropriate box)
° ° Petitioner ovant ° ° Other
in the above·entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintfpetltion/motion.
s In support of this application, I answer the following questions under penalty of perjury;
l. Are you currently incarcerated? ° ° °No (If "No" go to Question 2)
If "YES" state the place of your incarceration ii . lh ~ C . I ·
Inmate Identification Number (Required): ick 0 QZ E2
Are you employed at theiinstitution? Mg Do you receive any payment from the institution? Mg V
Attack rz ledger sheet from the institution of your incarceration showing ot least the gust six months’
transactions
2. Are you currently employed? ° ° Yes ` °
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. A
b. If the answer is "NO" state the date of your last employment, the amount of your tal
Valor u my dill 2** 7
3. In the past l2 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment · • Yes •
b. Rent payments, interest or dividends • · Yes • •
c. Pensions, annuities or life insurance payments * · Yes • •
d. Disability or workers compensation payments _ · · Yes · ·
e. Gifts or inheritances • • Yes · · i o
f. Any other sources · · Yes · · ®
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.
_ Case 1 :08-cv-00134-JJF Document 5 _ Filed O4/08/2008 Page 2 of 3 »
AO 1-10 Reverse (Rev. 10/U3] i
DELAWAEE SE?. QUE ` .
l 4. Do you have any cash or checking or savings accounts'? • • Yes
If "Yes" state the total amount $ ' I
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
y valuable property? D s
• • Yes @3
. ' ....,..-*'
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.
L 7
T y T [ [d¢‘Q€Ci"•[.id-Yi":) ,_,_,m_°,_:_[ D£_H/Iei,5_L6‘_飑¤
junio" cyl A .
g I declare under penalty of perjury that the above infomation is true and correct.
rt..i`tl¤t.....»l: prejndihe ‘>
[ [ Dk I to
tender Trelecsbi
NOTE T0 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 certiiied by the appropriate institutional
officer showing all receipts, expenditures, andbalances during the last six months in your institutionalaccounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certiiied
statement of each account.
Case 1 :08-cv-00134-JJF Document 5 Fnled O4/08/2008 Page 3 of 3
RESIDENT HISTORY REPORT Page 1 Of 1
HRYCI
01/31/oa 09:42
ST 007 / OPR SJW
S8I : 240623
Resident Name : OWENS, USHANGO
Time Frame : 08/01/2007 22:25 — 01/31/2008 09:42
Date Time Type ST GPR Receipt # Amount Balance
08/03/2007 09:45 Credit 11 WLH K4959 16.41 19.72
08/06/2007 13:44 Order 2 WLH 8179147 13.99 5.73
08/13/2007 10:40 Order 2 DDT 8180065 5.68 0.05
08/27/2007 08:55 Add 4 gmw D74482 260.00 260.05
08/27/2007 13:39 Order 2 DDT 8181977 58.63 201.42
08/28/2007 13:58 Credit _ 3 WLH C21888 10.34 211.76
08/31/2007 10:27 Withdrawal 6 SJW F31444 50.00 161.76
08/31/2007 10:33 Withdrawal 6 SJW F31447 100.00r 61.76
08/31/2007 13:41 Rec Payment 10 bsp J117H9 1.50 60.26
09/03/2007 10:44 Order 2 WLH 8182897 46.12 14.14
09/05/2007 13:25 Order 3 AFC C22028 2.20 11.94
09/10/2007 11:05 Order 2 DDT 8183878 11.85 0.09
09/21/2007 11:46 Add 4 J D76029 100.00 100.09
09/25/2007 05:34 Order 2 DDT 8185806 59.44 40.65`
10/01/2007 08:55 Add 4 gmw D76499 ` 24.00 64.65
10/01/2007 11:18 Order 2 DDT 8186705 30.51 34.14
10/02/2007 10:41 Credit 3 AFC C22867 1.10 I 35.24
10/02/2007 10:42 Order 3 AFC C22868 15.41 19.83
10/02/2007 10:44 Credit 3 AFC C22869 12.25 32.08
10/04/2007 13:21 Rec Payment 10 bep J12284 2.00 30.08
10/04/2007 14:57 Withdrawal 6 SJW F32276 16.00 14.08
10/08/2007 09:43 Order 2 DDT 8187577 14.06 0.02
10/29/2007 09:44 Add 4 gmw D78024 40.00 40.02
10/29/2007 10:22 Order 1 2 DDT 8190459 6.10 33.92
10/29/2007 13:49 Rec Payment 10 hep J12373 17.25 16.67
10/30/2007 11:27 Credit 3 WLH C23314 2.00 18.67
10/31/2007 11:56 Rec Payment 10 bsp J12391 10.45 8.22
11/05/2007 09:45 Order 2 DDT 8191292 3.63 4.59
11/07/2007 11:45 Rec Payment 10 bsp J12422 4.00 0.59
11/12/2007 09:02 Order 2 AFC 8192260 0.59 0.00
12/14/2007 11:29 Add 4 J D80807 100.00 100.00
12/18/2007 09:55 Order 2 AFC 8197383 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 1*34183 2.64 2.37
01/02/2008 06:19 Order 2 DDT 8199269 2.36 0.01
Case 1:08-cv-00134-JJF
Document 5
Filed 04/08/2008
Page 1 of 3
Case 1:08-cv-00134-JJF
Document 5
Filed 04/08/2008
Page 2 of 3
Case 1:08-cv-00134-JJF
Document 5
Filed 04/08/2008
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