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

Case 1 :07-cv-00466—Gl\/IS Document 6 Filed 08/14/2007 Page 1 of 4
AO 240 (Rev. I0/03)
DELAWARE Rev. 5/06 r
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Plaintiffi APPLICATION T0 PROCEED
V. WITHOUT PREPAYMENT OF
gmimcg FQMS Ming; FEES AND AFFIDAVIT
De endant(s)
CASE NUMBER: 07-466 GMS
I, “f SQ été Q LE gg g declare that I am the (check appropriate box)
@/ Petitioner/Plaintiff/Movant E Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings . d h t I m ti o t :__ elief _
sought in the complaint/petition/motion. § E L E g
In support of this application, I answer the following questions under penalty of p · jury illiilxi Ai
I. Are you currently incarcerated? i]/ Yes El No (If "No" to
. _ . .._. -
If "YES" state the place of your incarceration Q _ QE ig . ,.3 Q [tj
Inmate Identification Number (Required): [ [ Q
Are you employed at the institution? ,- gf; Do you receive any payment from the institution?
Attach a ledger sheet from the institution o[ your incarceration detailing all transactions over the past
sb: months. %
2. Are you currently employed? El Yes No
a. If the answer is "YES" state the amount of your tai 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?
a. Business, profession or other self—employment El Yes 34No
b. Rent payments, interest or dividends El Yes fo
c. Pensions, annuities or life insurance payments El Yes lj/No
d. Disability or workers compensation payments El Yes No
e. Gifts or inheritances E! Yes 290
f. Any other sources EJ Yes 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.

Case 1 :07-cv-00466—Gl\/IS Document 6 Filed 08/14/2007 Page 2 of 4
AO 240 Reverse (Rev. ID/0])
DELAWARE (Rev 5/06
4. D0 you have any cash or checking or savings accounts? El Yes %
lf "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? `
E! Yes o
If "Yes" describe the property and state its value.
6. Li·st 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.
I declare under penalty of perjury that the above information is true and correct.
.0l_._. . .` e
TE 5 j,. SIGNAT RE OF APPLICANT
NOTE TO 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.

~e -+-W-? Case 1:07-cv-00466—G|\/IS Document 6 Filed 08/14/2007 Page 3 of 4
Rmsxuem HISTORY REPORT Pwae 1 ¤f l
HRYCI
03/19/07 14:44
ST 006 / DPR KJG
SBI : 165136
Resident Name : WIMBLEY, JOHN
Time Frame : 05;’0'?/2006 17:56 · 03/19/2007 14:44
Date Time Type ST DPR Receipt: # Amount: Balance
06/0'U2006 17:56 Imzake 5 BVS 1215448 1.00 1.00
06/13/2006 12:11 Add · 4 SED D493B9 30.00 31.00
06/14/2006 09:41 Order 2 DDT B119632 20.08 10.92
06/21/2006 0B:36 Order 2 DDT 13120782 10.91 0.01

Case 1:07-cv-00466—G|\/IS Document 6 Filed 08/14/2007 Page 4 of 4
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