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

Case 1:08-cv-OO106—JJF Document 1 Filed O2/19/2008 Page 1 of 2 ‘s
’PORN E, (April l, 1977) \
DECLARATION IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS
Instructions to Court:
This form is to be sent tO the pf1SOner-plaintiff. G @ M F l O SJW
If there is reason to believe that the information received is not
accurate or complete, the court may want to use form 3 in addition.
Form 3 is an Order asking the records officer at the institution
to submit a certificate stating the current balance in the plaintiff‘s
institutional account.
Form 2 I
······* ·¤ isi]
. $9
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I L Insert appropriate court] gg %i,
L A /<. nsw//:1 yy]/e M.7 l W
[Petitioner] I I
vs. DECLARATION IN SUPPORT OF
REQUEST TO PROCEED
. IN FORMA PAUPERIS
;*0,mz‘sa‘r‘c/VGTYL C,!·¤·V`L<‘.., DQ/—J4f:I`>{fI;?’L,(¤ `—`—`_`_`
Respondent << {T A,,w
I, trwc»s~f# ·a~— ¢”#¤d*T am the petitioner in the above
entitled case. In support of my motion to proceed without being
required to prepay fees or costs or give security therefor, I state
that because of my poverty I am unable to pay the costs of said
proceeding or to give security therefor; that I believe I am entitled
to redress.
I declare that the responses which I have made below are true,
l. Are you presently employed? Yes No l )<
a. If the answer is yes, state the amount of your salary per
month and give the name and address of your employer.

b. If the answer is no, state the date of last employment and
the amount of the salary per month which you received.

Case 1 :08-cv-00106-JJF Document 1 Filed O2/19/2008 Page 2 of 2
2. Have you received within the past twelve months any money from
any of the following sources?
a. Business; profession, or form of self-employement? Yes __ No
‘ b. Rent payments, interest, or dividends? Yes __ No
c. Pensions, annuities, or life insurance payments? Yes __ No
d. Gifts or inheritances? Yes 3; No
e. Any other sources? iYes __ No
If the answer to any of the above is yes, describe each source of
money and state the amount received from each during the past
twelve months. 5/F7}
3. Do you own any cash or do you have money in a checking or savings
account? Yes No .x (Include any funds in prison accounts)
If the answer is yes, state the total value owned.
Q. Do you own.any real estate, stocks, bonds, notes, automobiles, or
other valuable property (excluding ordinary household furnishings
and clothing)? Yes __ No _;x ,
If the answer is yes, describe the property and state its
approximate value e ·
5. List the persons who are dependent upon you for support; state
your relationship to those persons; and indicate how much you
contribute toward their support.
I understand that a false statement or answer to any questions in
this declaration will subject me to penalties for perjury.
I Petitioner s Signature} n M
I declare under penalty of perjury that the foregoing is true and
correct. . n
Signed this fg ’ day of ~fa»J~a~¤r , 2?j§
__ js ' _.
, 2- “j?/ A;&Z;éf
(Signature]
G

Case 1 :08-cv-00106-JJF Document 1-2 Filed 02/19/2008 Page 1 of 1
Date :01/11/2008
Account Activity Ledger 1 img , 1 1 , O1.
From: 01/01/2007 To: l2/01/2007
J Tr; Batch Trx Balance
Comment Date Time {Inv # Trx # Type Invoice Deposit Withdrawal Forward
H 00343759 NameSHORT, LAKISHA Bkmk 8 l%ghgu5Bahncg 139.84
HP.1/9 01/09/2007 17:21 B#46828 377345 W -3.12 136.72
P/T.GRACE.MURRAY.SR. 01/11/2007 10:20 B#46868 377531 W -20.00 116.72
COMM.STORE.1/12 01/17/2007 13:36 B#46982 378057 W -37.86 78.86
Sales Transaction 01/23/2007 14:50 I#89448 I 46.53 32.33
COMM.CRDT.1/26 01/26/2007 17:01 B#47193 379388 D 2.00 34.33
KIT.PAY.12/24-1/27 01/30/2007 12:37 B#47242 379918 D 92.70 127.03
r COMM.STORE.2/2 02/03/2007 13:54 B#47315 380467 W -22.26 104.71
2 Sales Transaction 02/06/2007 10:41 I#89831 I 32.91 71.86
.. Sales Transaction 02/13/2007 12:03 I#90056 I 12.63 59.23
3 Sales Transaction 02/20/2007 10:23 I#90260 I 10.36 48.87
P/T.MICHAEL.CANNON.2 02/22/2007 14:09 8447639 382553 W -30.00 18.87
Sales Transaction 02/27/2007 11:15 I#90478 I 15.05 3.82
KIT.PAY.2/28 03/01/2007 12:49 B#47750 383472 D 14.94 18.76
Sales Transaction 03/06/2007 09:57 I#90704 I 16.02 2.74
COMM.CRDT.3/16 03/19/2007 15:43 B#48044 385558 D 16.02 18.76
Sales Transaction 03/27/2007 10:53 I#91370 I 13.04 5.72
PRCSD.REC.3/29.FR.3/ 03/30/2007 15:21 B#48272 386752 D V 20.00 25.72
Sales Transaction 04/03/2007 11:34 I#91601 I 21.72 4.00
MCP.5/18 05/21/2007 14:44 B#49278 393399 W -4.00 0.00
PRCSD.REC.7/19.FR.7/ 07/20/2007 11:07 B#50449 400506 D 40.00 40.00
MCP.8/5 08/14/2007 15:31 B#50969 403973 W -4.00 36.00
MCP.8/15 08/16/2007 13:25 B#51012 404253 W -4.00 32.00
Sales Transaction 08/21/2007 09:50 I#95830 I 31.71 0.29
PRCSD.REC.8/30 08/30/2007 16:51 B#51249 406054 D 10.00 10.29
PRCSD.REC.8/29 08/30/2007 16:54 B#51250 406070 D 20.00 30.29
Sales Transaction 09/11/2007 08:45 I#96522 I 27.95 2.34
MCP.9/24 09/25/2007 16:53 B#51733 409549 W -4.00 -1.66
PRCSD.REC.9/29 10/02/2007 16:14 B#51869 410342 D 25.00 23.34
PRCSD.REC.10/26 10/26/2007 15:52 B#52371 413642 D 25.00 48.34
Sales Transaction 10/30/2007 10:05 I#98042 I 47.97 0.37
PRCSD.REC.ll/1 11/02/2007 11:16 B#52484 414586 D 20.00 20.37
COMM.MEGA.KT.11/21 11/26/2007 12:40 B#52836 417111 W -7.00 13.37
Deposits 1 1 For 5 2 8 5 . 6 6
Withdraws 1 0 For S — l 3 6 . 24
Invoices 11 For S 27 5 . 8 9

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Case 1:08-cv-00106-JJF

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