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

lg T T Case 1:07-cv-00749-JJF Document 19 Filed 12/27/2007 Page 1 of 2
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UNITED STATES DISTRICT COURT T I I I
_ _ DISTRICT OF DELAWARE I
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Plaintiff APPLICATION TO PROCEED I
WITHOUT PREPAYMENT OF
V. FEES AND AFI-`IDAVIT I
p Defendant(s) _ A I CASE NUMBER: I I O4 ‘ C I/-UO I
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fp l'V@V\C··‘5 EYV}Or·`[ _ ____ declare that I am the (check appropriate box)
Petitione Iovant I] Other in the ahoveentitled proceeding; that in support of my
request to proceed without prepayment of fees or costs under 28 USC §l9l5, I declare that I arn ‘
unable to pay the costs of these proceedings and _that I am entitled to the relief sought in the
·.etition!rnotion.
In support of this application, I answer the following questions under penalty of perjury:
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1. Are you currently incarcerated? Efss Cl No (If "No" go to Question 2) I I I I I
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If "YES" state the place of your incarceration ,5 1/OP DEC 2 7 2007 I I
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Are you employed at the insrirutlon? El Yes `E'No us. aistmct coast I
_ · DISTRICT OF DELAWARE 7
Do you receive any payment from the institution? El Yes EM
Have the instintrion fz!] out the cerrificote norriori of this nftidavir and nrrcrc/2 rz Jedg er sheet from the
instirntion/sl of voor iricnrcemtion s/rowinp nt least the ansi SIX mom/rs' urmmczioris. Lec/cer .
sheets me not .··enuh·ed for crises filed gw·szio·m ro 28: USC §2254. I
2. Are you currently employed? El Yes EPNS l
a. if the answer is "YES" state the amount of your take—home salary or wages and pay period and I I
give the name and address of your employer. A; /,4 I
b. If the answer is "NO“ state the date of your last employment, the amount of your tai salary or wages and pay period and the name and address ofyour last employer. I
3. In the past 12 twelve months have you received any money from any ofthe following sources? I
a. Business. profession or other self—employ1nent I] Yes @{0
b. Rent payments, interest or dividends CI Yes (El/No ·
c. Pensions, annuities or life insurance payments I] Yes ?o
d. Disability or workers compensation payments . [I Yes No I
e. Gifts or inheritances D Yes E60 I
i`. Any other sources I] Yes E’§o I
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if the answer to any of the above is "YES" describe each source ofmoney and state theamount I
received AND what you expect you will continue to receive.

. M , ‘ Case 1:07-cv-00749-JJF Document 19 Filed 12/27/2007 Page 2 of 2
n_ DO you have any gash or checking or savings accounts? Cl Yes [2% ‘ . _ '
U If"Yes" state the total amount S _ T {
5_ s Do you Owneany real estate, stocks, bonds, securities, other tinancial in s,automobi1e5 0,- A ii
other valuable propertjv’? I] Yes t ’o
If"`Y'es" describe the property and state its value. ff l
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6. Y 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 .VO:\/E ift?licable.
I declare under penalty of perjury that the above infomation is true and correct. _
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Date: Sigmtute 0f`AQPli¤¤¤€ -
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Case 1:07-cv-00749-JJF

Document 19

Filed 12/27/2007

Page 1 of 2

Case 1:07-cv-00749-JJF

Document 19

Filed 12/27/2007

Page 2 of 2