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

Case 1:07—cv—001OQJGTIEM-EED'0cument 5 Filed 02/23/2007 Page 1 of 2
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FORM TO BE USED EVA PRISOILIEF FILIIIIG AN
APPL/CA TIOIV TO PROCEED IN F OR/1.6;, PA UPERIS
INA 42 U.5`.C. § 7983 C/VIL RIGHTSACTION
IN THE UNITED STA TES DIS TRIS T COURT ·
Foe me o.re..1·ict oe Delmoatie .
A L I. CAPTIOIV
Q kc wi — M ¢»
· (Entert the full name of plaintiff or O T T 1 O
piaintiffsi J "
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Ut (IYTLé*·fS! D!-K DGIQLKIGJQQ ag"
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(Enter the full name of defendant or no
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Instructions: -—**-
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The caption of this application should be identical tc tn: caption of the complaint. Aw
separate application must be completed by each plaintifr listed in the caption. Show yeirr rr
full name in the first line of the declaration belo vv. Pro·r.rde all information requested.
( 3 I II. DECLARQTIOIWI ,
[I {ygijr ngmgj M R GT W`, d9CI8fE3 ITIS? 1/ Em l`l'IE Dl5ll'ITI.7CT ll'?
the above—captioned 42 U.S. C. _§ 7983 civil rights action and that lan; entitled to proceed
Q forma gauperis pursuant to 28 U.S.C. E 7975 because of my inability to prepay the full
fee to file this action or give security therefor. l understand that the granting of Q fairy, I
gauperis status does not vvaive payment of the full filing fee. 1
lh further support of this application, l pro vide the follovving information; i [
7. Do you presently have prison employment? yes ( I ng
I 2. if you are not employed do you have other incomeV yes l I no if
3. if "yes " to either of above, state source of monthiw income and amount.
source _Q__ amoun t
4, ll "no, "state date andp/ace of last employment ance amount of monthly income.
date and place 1 ___g amount"
5. Do you have money in e prison account? yes: ( I amount`Â¥_`Z>~bZ} _
6. Do you have money in a ban/< account? yes I ’ nc I I amount
7. Do you ovvn or have an interest in valuable propert such an automobile
real estate, stoclrs, or bonds? yes i I no
if "yes, " describe property value

Case 1:07—cv—00109-GI\/IS Document 5 Filed 02/23/2007 Page 2 of 2
8. List the persons who depend on you for support, state their relationship to you, and -
how much you contribute towaro their support. ·
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9. State whether you have received within the past /2 rnonths any money from any ot
the fo//owing sources:
a. Business, profession or other torrn oi se/t—arnp/oyrnent yes ( J no /
. I I _ t _ `
o. r'-tent payments, interest or dividends yes { / no { M
c. Pensions, annuities lor /it‘e rnsurance payments yes ( / nof .
i d. Gitts or inheritances yes / / no tA/
I
e. Any other sources I yes // no ( / ·
/f the answer to any ot the above is "yes, ’“ describe each source of money I
ano’ state the amount received from each source ouring the past ii months. A
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iii. DECLAHA T/O/Li AND S/G/UA TUBE
/ dec/are under pena/ty o t periu ir ·· he foregoing is true and correct,
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S/G/VA TL/HE OF FLA!/\/TiFF DA TE
I IV. CERT/F/GA T/ON e _
instructions:
Request that an appropriate prison officiai provide: 7 ? the inforrnation pe/ow concerning
your inmate trust fund account balances; and 2/ e cer‘tifieo’ copy of your inmate trust fund
account statement showing a/J deposits and withdrevva/s for the prio· six—rnon th period.
, . . {T-. = -
/ certify that the app/rcant named herern has the sum of ` on account
to his credit at the ty 5 a it r"` ya , institution where he is
confined. fi VI I`? ‘*.,__ —..,.
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/ further certify th/at”o’uring= the iast six rnonths the asap/icant's--a vera oe rnonth/y account
a/a-nee was 5 / _ , ,4 and that the averape month/y deposits during the during
the iast s:ix.n·1on't’hs were F _j .
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I l hist E I he/krigw ) is "" {J W"' r/` ‘·
\ /'I' g`a_.·-?}`*?§YT·_’/ "`i `0 '
S; —MRt5’A/Y/D T/TLS OFAUTHOF?/ZED OFF/C/Aj DA TE
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