AO 240 (Rev. 10/D3)
DELAWARE;§Rev, 4£D5
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Q Piarntlrr APPLICATION TO PROCEED
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5\155Q2L CU mmwll Iv! Cong gl-`gonql ggtglfrl C- f4— ES LTVQ. FEES AND AFFIDAVIT
, ‘· , U Defendant(s) _ ¤l·f€
COA C bO°" maj'; 0 · Mwé, Rachael Mvrwovil I Mem; erase NUMBER; Q/I rt Jl 923
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I, ’iil°l~QOg leo ll [ fl S declare that I am the (check appropriate box)
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°[/ _,»·Petrtroner/Pilaintifffh/Iovant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed withou z. ·.;;s_;;¤;__q Q _
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings ncl that I a§ tghe relic `
sought in the complaint/petition/motion. o‘·= r ·· -·-··r R --e=e- ~ »-
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In support of this application, I answer the followinytuéions under penalty of erjur · i
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1. Are you currently incarcerated? 1 l/es ° °N0 (If "N0" 0 to QDuiésli<§[email protected] COURT"]
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If "YES" state the place of your incarceration P NSIVG
Inmate Identification Number (Required): #3
1 .
Are you employed at the institution? lu Q Do you receive any payment from the institution?
Attach o ledger sheet from the institution of your z`ncorcemtfon showing at least the gust sb: rnonths’
transactions ·
2. Are you currently employed? ° ° Yes 7%
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/fg
b. If the answer is "NO" state the date of your last employment, the amount of your talgjao e
salary or wages and pay period and the narne 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 • · Yes No
b. Rent payments, interest or dividends • · Yes
c. Pensions, annuities or life insurance payments · · Yes •
d. Disability or workers compensation payments • • Yes VK _
e. Gifts or inheritances · · Yes • " N
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.
_ _, Case 1 :07-cv-00783-JJF Document 3 Filed 12/O3/2007 Page 2 of 2
AO 240 Reverse (Rev. 1U/U3)
DELAWARE (Rev. 4,/U5
4. Do you have any cash or checking or savings accounts? • • Yes M6
If "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
` · · Yes · • o
If “Yes" describe the property and state its value.
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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.
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I declare under penalty of perjury that the above information is true and correct.
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DATE SIGNATURE OF APPLICANT
NOTE T0 PRISONER: 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 certiiied
statement of each account.
Case 1:07-cv—00783-JJF Document 3-2 Filed 12/03/2007 Page 1 of 2
» - s INMATE ACCOUNT STATEMENT
THEODORE ROLLINS 21-Nov-07
NAME SCCC ADMIT DATE
392812
DATE RELEASED
DATE DEPOSITS TYPE °{f DISBURSE Type °f BAi.ANcE
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 General/comrnissary
TRANSF Transfers to Ottier Institutions
SP. COURT Superior Court
TYPE OF DEPOSITS
M/O = money orders received outside of institution
B/R = booking and receivng
CK = checks
CASH
I/W = inmate wages
VIOLATION OF PROBATION/SCCC
I "Case 1:07-cv—00783-JJF Document 3-2 Filed 12/03/2007 Page 2 of 2
, . REQUEST FORM
` FOR
INMATE ACCOUNT ACTIVITY STATEMENT
Inmate Name: 0III B E I I lyeodagée SBINumber: ( Ig] $$2
(Last) (First) (M.I.)
Housing Unit: Ig O IQ » E ry ol I
In accordance with Bureau of Prisons Procedure 5.4 entitled "In Forma Pauperis", please provide a
summary of my account transactions.
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—~ QILAM __ • ILMIQV
Inmate Signature Notary . ‘
Inmate Account Activity Statement will be processed only after staff verifies your legal documents are
complete.
Date received by business office: I I I 2 I .
. ~ INMATE ACCOUNT STATEMENT
TO: Inmate Narne:
(Last) (First) (M.I.)
snr Number; e o 6l 9.3*1 L
Housing Unit: J o
FR: Inmate Account Technician
DA: n\7,Lr Io]
RE: Summary Of Account
Attached is ur a count statement for the six month period of
through I I IO I ·
Utilizing the cal ation fomiula described in BOP Procedure 5.4, your average daily balance for this
period is .
_ · ; '
* otary D r I .
Case 1:07-cv-00783-JJF
Document 3
Filed 12/03/2007
Page 1 of 2
Case 1:07-cv-00783-JJF
Document 3
Filed 12/03/2007
Page 2 of 2
Case 1:07-cv-00783-JJF
Document 3-2
Filed 12/03/2007
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Case 1:07-cv-00783-JJF
Document 3-2
Filed 12/03/2007
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