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

Case 1 :07-cv-00783-JJF Document 4 Filed 12/O3/2007 Page 1 of 2
AD 24D(Rev.1U,·'03) I
" DELAWARESRH. 4[D5 I
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Plaintiff y _ __ _ APPLICATION'TO OCE D
at-.lm+ amy, malveaafti +t»·M»n€·»>P;~j[€4t¤ f»#J rr wmrour pnnrxmnnr or
gggsm com m Umggy engr iam ( mg? O M- 5,} g i-arr? Ca/w/at FEES AND AFFIDAVIT
- _ 4 ~——· _ Defenda t(s
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I, l Ol KO ii/Mi V f i declare that I am the (check appropriate box)
PetitioneniPlaintifffMovant I- * _\° Other
Q______,____,-..——-—--~·—T""‘r··"*———».-_-.__./ r - vv- M -
in the above-entitled proceeding; that in support of my request to proceed without prepa E I " it `itmdere ·iI‘ ··
28 USC §1915, I declare that I am unable to pay the costs of these proceedings and t _. I a 7_•_ ` »§_lfg‘jgliefy __ ¤
sought in the complaintfpetition/motion. ` ``*`
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In Support of this application, I answer the followin ueSti0nS under peuelty of p¢1‘jUI __, _____”_ __
us.
1. Are you currently incarcerated? ° es ° °No (If "No" go to ii; _; _ | ‘ ~;:_· iE
If "YES" state the place of your incarceration ‘
Inmate Identification Number (Required): ’Q·· 3 3
Are you employed at the institution? A! O Do you receive any payment from the institution? Md
Attach :2 ledger sheet Qom the fn.s·1'z`tutf0rz of your irzcarceratzbrz showing at least the gust six m0nths’
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. /\//AI
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. N
3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other seltiemployment • - Yes • ,· __¤
b. Rent payments, interest or dividends • · Yes · » •
c. Pensions, annuities or life insurance payments · · Yes ·)‘)<'6`
d. Disability or workers compensation payments · • Yes · .
e. Gifts or inheritances • · Yes •/ o'?
f. Any other sources • · Yes · o
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.

W Case 1 :07-cv-00783-JJF Document 4 Filed 12/O3/2007 Page 2 of 2
AO 240 Reverse [Rev. 10/ 03)
DELAWAREEREV. 4!|]5
4. Do you have any cash or checking or savings accounts? · · Yes M
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? 1/
I · · Yes No
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 rnuch you contribute to their support, OR state NONE if applicable.
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I declare under penalty of perjury that the above infomation is true and correct.
ii I grit} I §£#`7’¢·;,.».?j, {%§fZ%)§/ j
DATE SIGNATURE OF A LICA
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 1:07-cv—00783-JJF Document 4-2 Filed 12/03/2007 Page 1 of 2
. INMATE ACCOUNT STATEMENT
TAKONIA NIEDLEY 10-Nov-07
NAME SCCC ADMIT DATE
257334
DATE RELEASED
DATE oeposirs Type We DISBURSE Typ° °f BALANCE
Deposit MENT Disburs.
$0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
$0.00 $0.00 $0.00 $0.00
TOTAL $0.00 $0.00 $0.00
$0.00
OPENING BALANCE
$0.00
ACCOUNT BALANCE
TYPE OF DISBURSIVIENTS
R/B room/board owed from previous visits to SWRU
MED = Visits to medical
TRANS = transportation owed from previous visits
P2 = Pay to's submitted thru business office
DG = Dollar Generai/commissary
TRANSF Transfers to Otner Institutions
SP. COURT Superior Court
TYPE OF DEPOSITS
NI/O = money orders received outside of institution
B/R = booking and receivng
CK = checks
CASH
I/W = inmate wages
VIOLATION OF PROBATION/SCCC

Caseit-i07-ov—00783-JJF s Document 4-2 Filed 12/03/2007 Page 2 of 2
REQUEST FORM
FOR
INMATE ACCOUNT ACTIVITY STATEMENT
Inmate Name: IE-jg (Tg {sing gf . SBI Number: (DOQ $7 $:53
(Last) (First) (M.I.)
I Housing Unit: 5/D J) · EQ Q l
In accordance with Bureau of Prisons Procedure 5.4 entitled "In Forma Pauperis", please provide a
summary of my account transactions. M
2/ »//z ” V
4 mm. . J ms' Liza).;
Inma e Signature __ Notary i O
Inmate Account Activity Statement will be processed only after staff verifies your legal documents are
complete.
Date received by business office: D .
INMATE ACCOUNT STATEMENT
TO: Inmate Name: mi QED/\Q VV
(Last) (First) (M.I.)
SBI Number: O O ZLQS 7 3- IB"}
Housing Unit: Mgg , E ub l
FR: Imnate Account Technician (
Di. t n | yp [ 0 7
RE: Summary Of Account
I Attached is yotiiéccount statement for the six month period of , O1
through i] ,O ] .
Utilizing the calglation formula described in BOP Procedure 5.4, your average daily balance for this
|· I H I U I V T» .
. ‘ A . -"`°
AU . A I 5 I
it g _,/ii} I yn. 5
Notary I

Case 1:07-cv-00783-JJF

Document 4

Filed 12/03/2007

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Case 1:07-cv-00783-JJF

Document 4

Filed 12/03/2007

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Case 1:07-cv-00783-JJF

Document 4-2

Filed 12/03/2007

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Case 1:07-cv-00783-JJF

Document 4-2

Filed 12/03/2007

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