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

Case 1:07-cv-00394—Gl\/IS Document 8 Filed 07/10/2007 Page 1 013 1 J
(R..,14m, C UNITED STATES DISTRICT COURT N ` h 1 a
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1 -—-— y_ ___, _1 __4_A_ A_______ =‘1 rift -11%*-‘?;11_‘1*"*'5·€l ` ‘ ,
· · 1 *-e- ·- 1 ` 1 `- WITHOUT PREPAYMENTOF _
1 1, 1 1I In FEES AND AFFIDAVIT 1
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Defendant(s) -" _ `?'g¤<;l1S.>:n I- C`C' if Ll C- It I _ 1
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I, :50fM O\\¤~?5¤V`\ - 1 1 declarethatl am the (check appropriate box) fl
lB/ pcnnouurpniinon/stov¤¤t” * 1`·‘ `1/· ` *”11 r El F ` " lil? II C I l
in the above—entitled proceeding; that in support of my request to pro ~· wit out prepayment Yf · or costs _
under 28 USC §1915, I declare that I am unable to pay the costs of these pr ceed ngs qluu tfhg lzggyen tled Q_ the 1 i
reliefsoughtinthe complaint/petition/mritipn;I_pW_ __ _:_ if plpi I ` ..p· _
In support of this application,-I answer the following questions under pen ‘1 1 ·1 Fa · ¤1!"2-1 F i· __ _ ;- -
1. · Are you currently 11 N01 (If "No'Y go to Question 2) __Q 1 1_ -1
- If_"YES"state the place ofyour incarceration Pi §hXgj_gQ;g§_`
U — you employed at the institution? T receive any payment from the institution'? 1h 1
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i 2. Are you currently '`"C l CD wi.` at Q I- 1 _ - J
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salary or wages and paypperiod and the name and _ad$;cgs of your last em loyer. 1
2_OOL¤ tl/\ l\Je»>c>»é_0c 1000-O0 0VNp-Ll3l\GL” p
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I 3. In the past 12 twelve months have you received any money from any ofthe following sources? -1 1
l a. Business, profession or other selféemployment n I C in I nail i 2
1 * b. Rent payments, interest or dividends U Yes Jo ' "
_ c. Pensions, annuities or life insurance payments p D Yes fo ·’ 1
,1 ` d. ` Disab_ilityp`iorIworkers1cpii1pensati6n·paynientsy{f H lCi""Yes in `'I`` _1 I `'`` /
` e. Gifts or inheritance: ¤ Yes 1--— o I
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I If the answer to any of the above is " YES" describe each source of money and state the amount ·- 1 _
`C _receivedAJ\*7)11wha1t youexpect you will continue toreceive, 1. 1111 1 1 1 1111 11 .111 1 1 11111 11 1111 ‘· '
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Case 1 :07-cv-OO394—Gl\/IS Document 8 Filed 07/10/2007 Page 2 of 3
4. Do you have any cash or checking or savings accounts? ¤Yes fsu n l
If *·v¤·· nm me mn amount I V.
5. Do you own any- real estate, stocks-, bonds, securities, other financial instruments, automobiles or other
valuable property? _ · » · Q
_ ¤Yes _ ${0 4
If "Yes" describe the property and state its value. _ , Q!
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.
I declare under penalty of perjury that the above information is true and correct:
’*l·jg——Q'*l·· _ _. . ` I { G mSf\ »———
- DATE . . . . SIGNATURE OF PLICANT
_ CERTIFICATE ` ·
. (Incarcerated applicants only) _ _
I certify that the applicant named herein has the sum of S ’ on account his/her credit at (name ~
or institution) ig lm`; 2 nj . ig, i lag lgyo Mw 5 QL"` Evil; a Sig . V.
I further certify that the applicant hasthe following securities to his/her credit: ~ ·
t V1 0 rw 6/ I A I
I further certify thatnduring the past six months the applicant's average monthly balance was S l
and the average monthly deposits were $_!_ · . .. I ·
t ’*t~@Lt+Of Z g§yj’](Z 2g.»4£Lgfe Egg; A
one g SIGNATURE or Avrno an omcmn . ~
(NOTE THE REQUIREMENT INITEMI FOR THE INMA TE TO OBTAINAADAZTACH LEDGER SHEETS
OF A CCOUNT TRANSACTIONS OVER THE PAST SIX MONTH PERIOD; LEDGER SHEETS NOT
REQUIRED FOR CASES FILED PURSUANT TO 28:USCԤ2254) i` ~-

Case 1:07-cv-00394i |§/I Qlocumengf Filed 07/10/2007 Page 3 of 3
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