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

· ` _ Case 1:07—cv—00777-Gl\/IS Document 1 Filed 11/28/2007 Page 1 of 2
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_ j DELAWARE Bev. " ' 3 · ! . .
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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r Plaintiff ` APPLICATION TO PROCEED
_ V. WITHOUT PREPAYIVIENT OF
\.jx\\ €;—\: $$5; FEES AND AFFIDAVIT
Defendant(s) ·
" CASE NUMBER: Y - Y }’ `?
I, S Egg; § ).—\ Q 2 ‘(\ declare that I am the (check appropriate box)
° ° Petitioner ovant ° ° Other l
in the above-entitled proceeding; that in support of my request to proceed without pre yment of fees or costs under
28 USC §l915, Ideclare thatl am unable to pay the costs of these proceedings and ‘e‘'` f ’‘‘‘‘
sought in the complaint/petition/motion. J .La.oo .... . _,__.“,
‘ In support of this application, I answer the following questions under penalty of perj : ` Nm 2 U [QQ! i
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1. Are you currently incarcerated? @ ° °No (If "No" go Ques t ·*
_ lf"YES" state the place ofyour incarceration G - , A ·. ,.,§ \`_ ‘ — §°§~. K .
. E Q r E E FO i—·= Ul
Inmate Identification Number (Required): Span
Are you employed at the institution? Do you receive any payment from the institution? NQ l-
Aitack a Fed er sheet [Bjorn the institution of your incarceration showing at feast the gas': sb.: mont}1s'
transactions -
2. Are you currently employed? ° ° Yes ° @ l
a. Ifthe 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. Ifthe 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 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment · · Yes $[0
b. Rentpayments, interestor dividends • · Yes i
c. Pensions, annuities or life insurance payments · · Yes
d. Disability or workers compensation payments · • Yes ` o A
e. Gifts or inheritances • • Yes
f. Any other sources · · Yes IEEE l
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.
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Case 1:07—cv—00777-Gl\/IS Document 1 Filed 11/28/2007 Page 2 of 2
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AO 240 Reverse (Rev. LD/03) .
DELAWARE Bev. UO? t _
V 4. Do you have any cash or checking or savings accounts? • • Yes ®
It "Yes" state the total amount $ ‘
S. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
_ valuable property? ‘
· ‘ Ye lib
I l 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 much you contribute to their support, OR state NONE if applicable.
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5\(\<,,·?.,<\C>~ Q€\®s%C3€\ ©`& QQKX 2, ®\`}g, %(j\ .
I declare under penalty of perjury that the above information is hue and correct.
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DATE - SIGNATURE OF APPLICANT .
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
I stating all assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional
officer sh owing all receipts, expenditures, and balances during the last six months in your institutional accounts.
H you have multiple accounts, perhaps because you have been in multiple institutions, attach one certiiied
statement of each account.
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Case 1:07-cv-00777—GI\/IS Document 1-2 Filed 11/28/2007 Page 1 0f 1
RESIDENT HISTORY REPORT Page 1 of 1
HRYCI
11/13/07 11:19
ST 007 / GPR SJW
SBI : 506146
Resident Name : MASON, MAROUIS
Time Frame . 06/01/2007 13:04 — 11/13/2007 11:19
Date Time Type ST OPR Receipt # Aznnunt Balance
06/12/2007 13:39 Order 2 DDT B172084 11.67 134.14
07/03/2007 13:51 Order 2 DDT B174959 13.00 121.14
07/06/2007 12:07 Add 4 SEA D717BB 80.00 201.14
07/10/2007 10:46 Order 2 DDT B175824 7.44 193.70
07/17/2007 09:43 Order 2 DDT B176753 4.66 189.04
07/24/2007 10:40 Order 2 DDT B177752 16.38 172.66
07/26/2007 13:40 Credit 11 WLH K4908 6.82 179.48
.08/01/2007 12:29 Order 2 DDT B178641 9.19 170.29
08/06/2007 12:09 Add 4 gmw D73393 100.00 270.29
_ _ 08/08/2007 13:03 Order 2 DDT B179583 10.89 259.40
08/14/2007 13:08 Order 2 DDT B1B0596 3.03 256.37
T 08/21/2007 13:34 Order 2 DDT B181574 5.82 250.55
08/29/2007 09:40 Order 2 DDT B182461 4.26 246.29 •
09/05/2007 10:19 Order 2 DDT B183417 10.06 236.23
09/11/2007 08:11 Rec Payment 10 bsp J12109 0.23 236.00 H
09/17/2007 12:35 Order 2 DDT B184924 10.88 225.12
09/25/2007 13:39 Order 2 DDT B1B6310 4.49 220.63 “
10/03/2007 13:17 Order 2 DDT B187225 9.83 210.80
10/17/2007 12:32 Rec Payment 10 bsp J12344 0.23 210.57
10/19/2007 06:26 Order 2 DDT B1B9143 11.19 199.38
10/22/2007 11:27 Credit 11 AFC K5791 4.06 203.44
10/23/2007 12:03 Add 4 J D77741 40.00 243.44
10 2007 12:39 Order 5 4.55 238.89
11/08/2007 : Order 2 DDT B19l865 3.20 225.69
11/08/2007 13:37 Credit 2 DDT 8191888 13.20 238.89
11/12/20 13:21 Order 2 AFC B192412 13.20 225.69
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Case 1:07-cv-00777-GMS

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Filed 11/28/2007

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Case 1:07-cv-00777-GMS

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Case 1:07-cv-00777-GMS

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