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

ase : -cv- - ocumen i e a e 0
C 1 07 00783 JJF D t1 FI d 12/03/2007 P g 1 f2
AO 240 (Rev. 1IJ/ 03)
DELAWARE [Rev. 4£05 I
NTED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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tee,/ar. on Y
g Plaintiff _ I APPLICATION TO PROCEED
Rlehrwr ee,.Jyr_ ne tml granite I /rirehna.5}¤¤»2/fr?/rrr/,¤; wrrnour PREPAYNIENT or
9v 56-%% Ctiwrnuni rl? CG"""£C`}'*O/'?‘·T{ C’·’»t17L€··’ C· W · S`: C ·t?·d·"¤/¤4 » FEES AND AFFIDAVIT
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we °· ‘ we 3 # · Mars ar e me Mae are NUMBER.
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I, SKLQUQU UO?} I declare thatl am the (check appropriate box)
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°J° Q’;—:ntiorie_1?:;E’lan1tift]’l\rIovant ° ° Other
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inthe above-entitled proceeding; that in support of my request to proceed without prep r. ____ ·»._·_·_ __p__ • _ _ p_:_ _ p.___
28 USC §l9l5, I declare thatl am unable to pay the costs of these proceedings and t at I am en@@ @ @ief
sought in the complaint/petition/motion. -, · or U ·‘‘‘· P P‘·‘ ‘ ‘·’·‘

,/ BEE) — il Emil
ln support of this application, l answer the followmg”questions under penalty of peijur : E g g
I r I _,.a,.. .a.....`.. ...,,....,. -.,.,,_,__,_Q °
1. A C mma e rea? ° • °No r "N ·· r rn st O pnerazcr cenet
IC yOU Ll Y IH HICCIH. )/.1fGS (I O gO O gr LI I I
lf "YES“ state the place of your incarceration 5 ]?
Inmate Identification Number (Required): /0 5 3
Are you employed at the institution? #’°’ O Do you receive any payment from the institution? &/ O
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast six months ’
transactions ‘ g
2. Are you currently employed? ° ° Yes °V§
a. lf 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. /_/AQ-
b. lf 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 employerw
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 -4
b. Rent payments, interest or dividends • · Yes ,-**916
c. Pensions, annuities or life insurance payments · • Yes · • No
d. Disability or workers compensation payments • • Yes •;*?ler
e. Gifts or inheritances · · Yes ·[/I?
f. Any other sources • • Yes • o
lf 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.
M , ft

Case 1 :07-cv-00783-JJF Document 1 Filed 12/O3/2007 Page 2 of 2
_ l-
AO 240 Reverse (Rev. ID/(B)
DELAWARE {Rev. 4£(15!
4. Do you have any cash or checking or savings accounts? • • Yes ·(_:.»No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobile or other
valuable property?
• • Yes o
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
A indicate how much you contribute to their support, OR state NONE if applicable.
s i< » ·=· Hear
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T; t a — eoos: rv
I declare under penalty of perjury that the above information is true and correct.
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.

I Case 1:07-cv—00783-JJF Document 1-2 Filed 12/03/2007 Page 1 of 2
. · · * INMATE ACCOUNT STATEMENT
KEENAN WRIGHT 28-Aug-07
NAME SCCC ADMIT DATE
431053
DATE RELEASED
DATE beposirs Type $f DISBURSE Type Of sALANcE
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 DISBURSMENTS
R/B room/board owed from previous visits to SVI/RU
MED = Visits to medical -
TRANS = transportation ovved from previous visits
P2 = Pay to's submitted thru business oftice
DG = Dollar General/commissary
TRANSF Transfers to Other 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

. Case 1:07-cv—00783-JJF Document 1-2 Filed 12/03/2007 Page 2 of 2
REQ QUEST FORM
FOR
[NMATE ACCOUNT ACTIVITY STATEIWENT
Inmate Name: Li lr E€»6,[l£&/I SBI Number: QV}
(Last) (First) (MJ.)
Housing Unit: lg 9 p / Q Gl} [
In accordance with Bureau of Prisons Procedure 5.4 entitled "In Forma Pauperis", please provide a
summary of my account transactions. I/_ __;_____ ·· U \
I / \\ ~v P li `
Aa%{% <@r ,;··· A E
Inmate Signature Notary i •‘
Inmate Account Activity Statement will be processed only after staff verifies your legal documents are
complete.
Date received by business office: I I I U I . A
[NMATE ACCOUNT STATEMENT
T0: Inmate N¤m·==
(Last) (First) (Ml.)
SBI Number: ODWBI US 5
Housing Unit: Vol} —* EQ Q [
r F R: Inmate Account Teclmician
RE; Summary Of Account
Attached `s ur ace unt tement for the six month period of 5 { /I
through rl .
Utilizing t ' lnll ll lation formula described in BOP Procedure 5.4, your average daily balance for this
period is $ . . -
$/,,)_,...»»— r Ghm r I >_ u
I ‘ -»·· _ _ ( .
N w I a

Case 1:07-cv-00783-JJF

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Case 1:07-cv-00783-JJF

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