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

` ' Case 1 :08ecv-00099-GIVIS Document 1 Filed O2/14/2008 Page 1 of 2
AO 240 (Rev. l0I03)
DEL.·\WAREjRev. 4»'052
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
U 8 " O 9 8 no
Q lttmwx Qgr Y feelfl"'
Piamarr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
Y im irq 2 5 aaa; me was yar-.5rJ{ FEES AND AFFIDAVIT _ _
I Defendan (s) l
v\M<&»?~¤—#t¢» lirwivl t~LA— ` CASENUMB ‘ .. . _PP1 .r -- .1..—. » ··.-» I
I, 5 “ lg Qtr;)/1 ( Q E5 gz Ll/‘1" declare that I a the Q ‘ to tls `i i;
_ ,. Y i
lil Petitioner/Plaintiff/Movant lj Other l 4
in the above—entitled proceeding; that in support of my request to proceed witho pre iiig und r
28 USC §l9l5, I declare thatl am unable to pay the costs of these proceeding te .¢le: .=?»in3»..<. . .. c.?
sought in the complaint/petitioit/motion. .
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? E Yes Cl No (lf "No" go to Question 2) `
if "YI-ES" state the place of your incarceration Ee-Q; [-·aL:(;l»Qr~, §.O.§?2(;,; QZO "`\;a{i rj .4 `lJ_”'""Q QQGZD
Inmate Identification Number (Required): fl DCI 8 7* E>§'O _
.\t.SL?»,c>o/in ¤·¤—¥\#x
Areyou employed at the institution'? le-S D0 you receive any payment from the institution? Z e 5
Attach a ledger sheet Qorn the institution of your incarceration showing atleast the gast six months '
transactions
2. Are you currently employed? El Yes Mite
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.
3. In the past l2 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment E1 Yes ¤ No
b. Rent payments, interest or dividends III Yes H No
c. Pensions, annuities or life insurance payments E1 Yes W No
d. Disability or workers compensation payments III Yes § No
e. Gifts or inheritances E1 Yes B No
_ f. Any other sources A Ct Yes ft No
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 :08-cv-OOO99—Gl\/IS Document 1 Filed O2/14/2008 · Page 2 of 2 " O A
AO 240 Reverse (Rev. l0.’tl3) r _
DELAWARE Ev. 4f05 ` ` - `
4. Do you have any cash or checking or savings accounts? El Yes 5 No
If "Yes" state the total amount $
S. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
valuable property? _
` E1 Yes E No .
If "Yes" describe the property and state its value. U
- 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. ·
I declare under penalty of perjury that the above information is true and correct. ‘
ieZ0O8
DATE SIGNAT OF APPLICANT ·
NOTE TO PRISONER: i A Prisoner seeking to proceed without prepayment of fees shall submit an
afiidavit 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-00099-GIVIS Document 1-2 Filed O2/14/2008 Page 1 BL 2
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General Intbrmatton ] Account Balances 1 l Commissagg Histog l Commissag Restrictions l Comments
General Information 1
Administrative Hold Indicator: No .
No Power of Attomey: No
A Never Waive NSF Fee: No _
Max Allowed Deduction %: 100 _ i
PIN: 0649
PAC #: 829543531 `
FRP Participation Status: . Participating A
Arrived From: i I
A Transferred To: 1
n Account Creation Date: 1/25/2006 1
Local1Account Activation Date: lf26/2006 8:57:43 AM _
Sort Codes: __`_`_ K 1
_ Last Account Update: 1Il4.’2008 11:48:02 AM
~ Account Status: Active
I Phone Balance: $3.69 n _
FRP Plan Information ` 1
FRP Plan Type Expected Amount Expected Rate
Quarterly $25.00 0% 2
Account Balances '
Account Balance: n $11173 " V
Pre»Re1ease Balance: $0.00 _
Debt Encurnbrance: $44. 1 9 _ 1
U SPO Encumbrancc: $0.00 2 1 _ _
Other Encumbrances: $0.00 n - n '
Outstanding Negotiable Instruments: $0.00 ‘ I
Administrative Hold Balance: $0.00 _ n
Available Balance: $73 .54 2
_ National 6 Months Deposits: $1,943.24
National 6 Months Withdrawals: $1,871.00 _ 1 A
National 6 Months Avg Daily Balance: $118.02 - 1
Local Max. Balance - Prev. 30 Days: $222.48
Average Balance - Prev. 30 Days: $1 13.37 _ _ i `
http://10.3 3.43.1 07/UMR/ImnateInquiryCombined.aspx 1 11/14/2008

" · t Case 1 :08-cv-00099-GMS Document 1-2 Filed 02/14/2008 Page 2 pf 2
_ age 2 of 2
Commissary History . U
Purchases
Validation Period Purchases: $93-$0 " _ -.
YTD Purchases: $687.30
Last Sales Date: 1/9/2008 5:16:03 PM
` SPO Information
SPO's this Month: 0 -
SPO $ this Quarter: $0.00 ` _ `
Spending Limit Info. ` ‘
Spending Limit Override: No ` i
. Weekly Revalidation: No 7
Bi-WeeklyReva1idation: No
Spending Limit: $290.00
Expended Spending Limit: $9310
Remaining Spending Limit: $196.90 -
Commissary Restrictions A ` _ .
Spending Limit Restrictions l
Restricted Spending Limit: $0.00 -
Restricted Expended Amount: $0.00 · · -
Restricted Remaining Spending Limit: $0.00
Restriction Start Date: N/A _
Restriction End Date: N/A ‘
Item Restrictions ` L
List Name List Type Start Date 7 End Date Active ·
Comments n
n Comments:
http://10.33.43.107/UMR/InmateInqui1·yCombined.aspx » 1/ 1 4/2008

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