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

I I Case 1 :07-cv—00485-JJF Document 1 Filed 08/06/2007 Page 1 of 2
I ;\O 240 [Rev. 10/03} I
. DELAWA.REtRev. 4/U5! I I
I UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE i
raintirr I APPLICATION TO PROCEED
V. _ . WITHOUT PREPAYMENT OF
._·,;__ 1 r, . ·.‘ ‘ p ,(.._as _ ;_· \.· ,..·- FEES AND AFFIDAVIT
Defendant(s)
_ ` _ CASE NUMBER: gi; O 7 " A 8 5 ‘
I, C) ¤ ;—SO§yg,§ No V declare that I am the (check appropriate box) i
lE/ Petitioner/Plaintiff/Movant El Other
l
in the above—entitIed proceeding; that in support of my request to proceed without p · _» . u e o ost nder *
28 USC §l9I5, I declare that I am unable to pay the costs of these proceedings a ,• that [ 1 ‘ 6
sought in the complaint/petition/motion. Q -- l a~ . e A ..;e= ~~ V C
nn nn
In support of this application, I answer the following questions under penalty of pe ury: p
l. Are you currently incarcerated? lg/Yes `El No (If "No" go o cl; »· J
._r, _ r_tt,`..l l . i ..l`t.=. ..,.t in _.
If "YES" state the place of your incarceration 1 {Q jr I { ‘ .
_ Inmate Identification Number (Required): E Q ll-l, l i
i
Areyou employed at the institution? {NO Do you receive any payment from the institution? gy)
l
Attach a ledger sheet Qjorn the institution of your incarceration showing at least the past six months '
transactions
l
2. Are you currently employed? El Yes Ego l
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. _
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.
3. _ In the past 12 twelve months have you received any money from any of the following sources? I
a. Business, profession or other seltiemplcyment E1 Yes III No
b. Rent payments, interest or dividends E1 Yes E1 No
c. Pensions, annuities or IIIC insmance payments E1 Yes Ei No _
. d. Disability or workers compensation payments E1 Yes E1 No ·
e. Gifts or inheritances (Yes D No
f. Any other sources El Yes El No
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. _
c9~5O¤ OOél|@\b / Y€,£.l\l€a (IDD n .

Case 1 :07-cv—00485-JJF Document 1 Filed 08/06/2007 Page 2 of 2 , , _
AO 240 Reverse (Rev. ID/03) I
DE.LAWA.l\Ej§ev. 4/052 ` » `
4. Do you have any cash or checking or savings accounts? U U Yes E/No
If "Yes" state the total amount $ ( 2tOl 2
5. Do you own any ral estate, stocks, bonds, securities, other financial instruments, automobiles or other
. valuable property? ‘
l _ E1 Yes I1!/No .
If "Yes" describe theproperty 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. ·
J`., . . Yi (Y—0c\#\»»e<>.j IQOMQJ .
- · f
T .-t- tgt cioakeah Meme
l declare under penalty of perjury that the above information is true and correct.
DATE ;i - é SIGNATé% OF APPLICANT ·
NOTE TO PRISONER: i 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 E
institutions, attach one certified statement of each account.

q y _ _ Case 1:07-cv-00485-JJF Document 1-2 Fnled 08/06/2007 Page 1 of 1
RESIDENT HISTORY REPORT Page 1 cf 1
HRYCI
07/11/07 10:54
ST 007 / 0PR SJW
SBI : 191747 _ `
Resident Name : JOHNSON, SCOTT 0
Time Frame : 02/11/2007 09:11 — 07/11/2007 10:54 ai _
A 807 4858
Date Time Type ST OPR Receipt # Amount Balance
02/26/2007 10:01 Add 4 CAR D64362 50.00 50.08
02/26/2007 10:01 Add 4 CAR D64363 50.00 100.08
02/27/2007 06:32 Order 2 AFC B157119 59.09 40.99
02/28/2007 11:53 Rec Payment 6 kjg F26197 1.17 39.82
03/01/2007 10:11 Credit 11 AFC K3082 3.40 43.22
03/02/2007 15:16 Rec Payment 10 bep J8608 2.50 40.72
03/05/2007 12:58 Order 2 DDT B157987 31.11 9.61
03/07/2007 11:42 -Rec Payment 10 bsp JB651 1.00 8.61
03/07/2007 11:46 Rec Payment 10 hep J8660 0.75 7.86 _
03/08/2007 08:11 Rec Payment 10 bep J8687 0.75 7.11 f
03/08/2007 08:22 Rec Payment 10 hep J8690 6.75 0.36 E
' 03/14/2007 06:25 Order 2 DDT B159331 0.26 0.10 {
05/07/2007 10:18 Add 4 CAR D68395 15.00 15.10 V
* 05/07/2007 14:43 Rec Payment 6 kjg F28783 10.92 4.18
» 05/07/2007 15:38 Rec Payment 6 kjg F2B784 0.39 3.79
05/08/2007 11:18 Rec Payment 6 kjg F28800 0.39 3.40
05/11/2007 15:18 Rec Payment 10 hep J10092 0.45 2.95
05/14/2007 05:56 Order 2 DDT B167478 ` 2.73 0.22
05/31/2007 11:48 Add 4 gmw D69779 22.00 22.22
06/01/2007 14:42 Rec Payment 7 SJW G11543 0.41 21.81
06/01/2007 14:50 Rec Payment 7 SJW G11547 0.41 21.40
06/04/2007 09:44 Add 4 CAR D69930 70.00 91.40
06/05/2007 09:41 Order 2 DDT B170950 52.78 38.62
06/08/2007 09:35 Rec Payment 7 SJW G11574 0.41 38.21
06/08/2007 09:45 Rec Payment 7 SJW G11577 0.41 37.80
- 06/08/2007 09:48 Rec Payment 7 SJW G11578 0.41 37.39
06/12/2007 10:36 Order 2 DDT B171987 25.95 11.44
06/14/2007 10:20 Rec Payment 10 bep J10634 1.00 10.44
06/19/2007 08:39 Order 2 DDT B172939 10.33 0.11
1 AUG -8 EGG?

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