i it AO 2AO iRzv.10/D3) l
DELAWARE gev. 4;*05 ` ·
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Bug it E tk- C; oubti s.\—\
_ Piuaurr APPLICATION T0 PROCEED
V. WITHOUT PREPAYMENT OF
`.I2;v, cg! ie.; g4Li»..er~·g-· iS>u.\J% eq-;-l··-·:·..i FEES AND AFFIDAVIT
Defendant(s) . .
CASE NUMBER: '
U G T ·~· 7 6 l
I, I’;‘;,1\}LL`§`, I} · {,0 iq; g 3 5 H declare that I am the (check appropriate box)
° ° Petitioner/Plaintiff/Movant ° ° Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion. .V.. ._._. . ._;. .. . - .i-» » *·
In support of this application, I answer the following questions under penalty of QQV A
. V Q} if]. ___i_ . Z
I. Are you currently incarcerated? ° gas) ° °No (If "No" gin to Qi estion 2) i
I i ' i
If"YES" state the place of your incarceration .. - _, { “ ` · _ ._ ‘ I r_; r _ p_;iJ_.i.;§ *
I llviv n FD sc NJ
Inmate Identification Number (Required): § r I3; 1;% I SI5 jf 9/ dm
Are you employed at thelinstitution? L`! O Do you receive any payment from the institution? jig; l
A Attach a ledger sheet Qom the institution of your incarceration showing at least the past sbt months '
transactions
2. Are you currently employed? ° °@ ` ° No
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. I
b. If the answer is "NO" state the date of your last employment, the amount of your take—home
_ salary or wages and pay peripd and the name an_d address _of your last employer. I
Q4-lr ii 200 Co %7RfLdLf’5' ig/°`(}(I}(Ki(3{é' fqfzéi »
3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment • · Yes • •
b. Rent payments, interest or dividends • · Yes • · io
c. . Pensions, annuities or life insurance payments · · Yes • •
cl. Disability or workers compensation payments • • Yes ·
e. Gifts or inheritances · · Yes • · iw
f. Any other sources • • Yes • · tw
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-00761-JJF Document 1 Filed 11/26/2007 Page 2 of 2 _,
AO 240 Reverse (Rev. `IEUD'3)
DELAWARE (Esta 4/05] l .
l 4. Do you have any cash or checking or savings accounts? • · Yes • (No?
If "Yes" state the total amount $ ‘
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘
· • Yes • @
_ 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.
it is M Cz'
g I declare under penalty ofperjnry that the above information is true and correct. A
/;A?og'e`;· Z gggé gQgm,Q,(
DATE - SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment ol` fees shall submit an aftidavit
stating all assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional
ofticer showing all receipts, expenditures, andbalances 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.
SRV
‘· Case 1:07-cv-00761-JJF Document 1-2 Filed 11/26/2007 Page 1 of 1
RESIDENT HISTORY REPORT page 1 Of l
11121:01
11/13/07 11:29 i?
ST 007 / DPR SJW E
sex = J-E8491
Resident Name =_. `CORNISH, BLANE
Time Frame : 06/01/2007 02:08 — 11/13/2007 11:25
Date Time Type ST OPR Receipt # Amount Balance
07/09/2007 09:06 Order 2 DDT B175311 0.33 0.03
07/09/2007 14:15 Add 4 SEA D71894 20.00 20.03
07/16/2007 09:20 Order 2 DDT B176226 19.99 0.04
07/30/2007 08:23 Add 4 gmw D72B85 50.00 50.04
08/06/2007 09:25 Order 2 WLH 8178956 29.85 20.19
08/13/2007 09:24 Order 2 DDT B179941 18.82 1.37
08/14/2007 09:39 Add 8 bef H32744 20.00 21.37
08/17/2007 11:16 Rec Payment 10 bsp J11626 1.00 20.37
08/17/2007 11:47 Rec Payment 10 bsp J11635 2.50 17.87
08/17/2007 14:32 Rec Payment; 10 bsp J11660 5.00 12.87
08/20/2007 09:22 Order 2 DDT E180976 12.78 0.09
09/04/2007 10:27 Add 4 gmw D74905 20.00 20.09
09/10/2007 10:22 Order 2 DDT B183788 13.21 6.88
09/17/2007 10:01 Order 2 DDT B184734 5.90 0.98
10/09/2007 10:46 Add 4 J D76961 20.00 20.98
10/09/2007 10:46 Add 4 J D76962 20.00 40.98
10/1672007 05:39 Order 2 DDT H188577 21.22 19.76
10/22/2007 09:03 Order _ 2 DDT B189458 19.15 0.61
Case 1:07-cv-00761-JJF
Document 1
Filed 11/26/2007
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Case 1:07-cv-00761-JJF
Document 1
Filed 11/26/2007
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Case 1:07-cv-00761-JJF
Document 1-2
Filed 11/26/2007
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