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

Case 1 :08-cv-00129-GIVIS Document 1 Filed O3/O4/2008 Page 1 of 4 ,
~ _ , AO 2dCl {Rzv.10!03) _
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, Plaintiff APPLICATION TO PROCEED
V. VVITHOUT PREPAYMENT OF
§,_,_ rm,. :5; P,. .r_ gs Se- FEES AND AFFIDAVIT
Defendant(s) . O 8 __ 1 2 Q
CASE NUMBER:
I, ’iY"E"`~·»€Z 3 ». lLT_§*r·s-.%*s;1*$\ La. i*:3--Fir-~t;}~-bjs=§>{~"a. declare that I am the (check appropriate box)
° ° Petitioner;§§l;;dd;fI7g~/lovant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintfpetitionfrnoticn.
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? ° ° °No {If "No"i go to Question 2)
If "YES" state the place of your incarceration 5 3; 3 3 gg ”; dia {gk ~· %.w}—,__§ gg.; tr?
Inmate Identification Number (Required): ES G QQ "3 Lj`“·\§u
Are you employed at theinstitution? ¥§g§ Do you receive any payment from the institution? ss}; 3 `Q l
l Attach a ledger sheet Qom the institution of your incarceration showing at least the gast srl: month! I
transactions I ‘
2. Are you currently employed? ° ° Yes ° Mgr;
_ 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. '
I 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 • • Yes • •@
b. Rent payments, interest or dividends • • Yes • •k®
c. Pensions, annuities or life insurance payments • · Yes ' '@
d. Disability or workers compensation payments • • Yes • gid)
e. Gifts or inheritances • • Yes · •,&.t;•"
f. Any other sources · • Yes · .
If the answer to any of the above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive. ‘

_ Case 1:O8—cv—OO129-Gl\/IS Document 1 Filed O3/O4/2008 Page 2 of 4 .. -
AO '2.·fU Reverse (Rev. 10/D3)
DELAWARE §ev. QUE] l
l 4. D0 you have any cash or checking or savings accounts? · · Yes •
If "Yes" state the total amount $ ‘
S. Do you own any real estate, stocks, bonds, securities, other financial instrtunents, automobiles or other
valuable property? I . p
· • Yes ·
p 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. age;-,\_r_~»;,,%··,__ x tp lx ;___g‘;p?·\·4[.;_,
. I · ‘
q5=$$-»`?‘~i€3.s ‘§Z;;s®"’§”“s ·¤ $>a-sim g:,_;t,_t;,,s,., ... can CW
t.Q?<·;gs“;_,.v,vc"=~».sTi*,; ""<·:raiZ;;si£¥;§s`€1s=£,;*=s “»».°§i;> , €.Q%s;j,i€‘·¤`“€`\€€`ir a -
7 I declare under penalty of perjury that the above information is true and correct.
P gg; 13 · tg eg 3=~s~».&_ .s..@»..§'&.. Q aesesisssesesea
DATE - SIGNATURE OF APPLICANT
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 certified by the appropriate institutional
officer 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-00129-GIVIS Document 1 Filed O3/O4/2008 Page 3 of 4
RESIDENT HISTORY REPORT Pagé 1 ¤f 1
.:· 43;;
SBI : 506146
Resident Name : MASON, MARQUIS
Time Frame : 09/01/2007 13:04 - 02/27/2008 13:39
Date Time Type ST OPR Receipt # Amount Balance
09/05/2007 10:19 Order 2 DDT B183417 10.06 236.23
09/11/2007 08:11 Rec Payment 10 bsp J12109 0.23 236.00
09/17/2007 12:35 Order 2 DDT B184924 10.88 225.12
09/25/2007 13:39 Order 2 DDT B186310 4.49 220.63
10/03/2007 13:17 Order 2 DDT B187225 9.83 210.80
10/17/2007 12:32 Rec Payment_ 10 bsp J12344 0.23 210.57
10/19/2007 06:26 Order 2 DDT B189143 11.19 199.38
‘ 10/22/2007 11:27 Credit 11 AFC K5791 4.06 203.44
10/23/2007 12:03 Add 4 J D77741 40.00 243.44 ‘
10/23/2007 12:39 Order . 2 DDT E190025 4.55 238.89
, 11/08/2007 07:44 Order 2 DDT E191865 13.20, 225.69
11/08/2007 13:37 Credit 2 DDT El91888 13.20 238.89-
11/12/2007 13:21 Order n 2 AFC E192412 13.20 225.69
11/30/2007 11:31 Rec Payment 7 SJW G13210 4.50 221.19
11/30/2007 11:50 Rec Payment 7 SJW G13217 5.00 216.19
12/04/2007 11:09 Order V 2 AFC El95657 14.79 201.40
12/10/2007 12:16 Order 2 AFC B196249 1.30 200.10
12/19/2007 06:37 Order 2 AFC E197598 10.93 189.17
01/02/2008 10:12 Order 2 DDT 8199471 8.12 181.05
01/15/2008 13:21 Order 2 DDT E201397 10.42 170.63
01/22/2008 12:20 Order 2 DDT E202303 7.52 163.11
01/28/2008 10:01 Add . 4 gmw D83230 65.00 228.11
01/30/2008 09:41 Order 2 DDT E203202 5.73 222.38
02/05/2008 10:55 Order 2 AFC B203923 5.70 216.68
02/11/2008 11:41 Add 4 J D84197 10.00 226.68
02/11/2008 11:42 Add-Rev 4 J DB4198 10.00 216.68
02/12/2008 10:58 Order 2 DDT B204943 1.80 214.88
02/18/2008 12:55 Order 2 DDT B205615 6.78 208.10
02/21/2008 15:03 Withdrawal 6 SJW F35602 32.90 175.20
02/21/2008 15:04 Withdrawal 6 SJW F35603 33.95 141.25
_ 02/26/2008 11:02 Order 2 AFC E207020 1.71 139.54

‘ " Case1:O8—cv-00129-GMS_ D0cument1 Filed O3/O4/2008 Page40f4
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Case 1:08-cv-00129-GMS

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Filed 03/04/2008

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Case 1:08-cv-00129-GMS

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Case 1:08-cv-00129-GMS

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Case 1:08-cv-00129-GMS

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