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

Case 1 :08—cv—00073-Gl\/IS Document 8 Filed 04/18/2008 Page 1 of 3
=\O 2·1II(I{nv I0/UCI)
l')FL:\\’vr\RE [Rev 4/05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
t)cLtJl Circ] lo, Q5; t
Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
Defendantts) ,
CASE NUMBER: O 7 5
I, \>[ gyti gnr , lr c cmg L I declare that I am the (check appropriate box)
fl Petitioner/Plaintift7I\/lovant D Other
in the above-entitled proceeding; that in support of my request to proceed without prepay ·· · - · • nr . _ ,
28 USC §I9I5, I declare that I am unable to pay the costs ofthese proceedings and th I am entitFl Iomjgenf
sought inthe complaint/petition/motion.
APR I 23 ZUU8
In support ofthis application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? E Yes mic (If "No" go to Q stion 6%S- COURT
TRICT OF DELAWARE
If"YES" state the place of your incarceration GO 5'€`¢·`*¤¤cf
Inmate Identification Number (Required):
Are you employed at the institution'? Do you receive any payment from the institution?
Arms/2 rz /ec/ger sheer [.··om the fnsrirzrtion at jour incc1.··cer0rion showing crt least the past sixiwwnr/1s’
1mm·crcrion.s·
/
2. Are you currently employed? El Yes E 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 ofyour employer.
b. Ifthe answer is "NO" state the date ofyour last employment, the amount of your take—home
salary or wages and pay period and the name and address ofyour last employer.
3. ln the past I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other seltlemployment El Yes U No
b. Rent payments, interest or dividends Cl Yes E1 No
c. P'<;t1siei1s_\an11ttities or life insurance payments E1 Yes U No
d. FDisability:- or workers compensation payments i¤"’Yes Cl No
e. Gifts ofinheritances D Yes Ei No
I`. Any other sources U Yes El No
Ifthe answer to any ofthe above is "YES" describe each source ofmoney and state the amount
received A ND what you expect you will continue to receive.
ff s sryma 3>rsa.t.. lily

Case 1:08—cv—00073-Gl\/IS Document 8 Filed 04/18/2008 Page 2 of 3
AO 240 Revs-rsp (Rex- 10/ 03)
DELAWARI; (Rev 4/U5)
4. Do you have any cash or checking or savings accounts? D Yes El/No
lf "Yes" state the total amount 55
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
valuable property?
in Yes KU/No
lt` "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 ifapplicable. M O Aj L
l declare under penaity ot` perjury that the above information is true and correct.
JU aaa 3 E
/ / · L ‘ ¤
DATE SIGNAT E OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an aflidavit
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 ccrttlied
statement of each account.

Case 1:08—cv—00073-GI\/IS Document 8 Filed 04/18/2008 Page 3 of 3
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Case 1:08-cv-00073-GMS

Document 8

Filed 04/18/2008

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Case 1:08-cv-00073-GMS

Document 8

Filed 04/18/2008

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Case 1:08-cv-00073-GMS

Document 8

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