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

_ _ Case 1 :06-cv-00715-SLR Document 1 Filed 11/29/2006 Page 1 of 2 y I
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DELAWARE {Rev. 4fD5`§
P UNITED STATES DISTRICT COURT l
DISTRICT OF DELAWARE
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Piamtrrt APPLICATION TO PROCEED
v. N r WITHOUT PREPAYMENT OF
s Ogr DE/rl Gaze ~"
(577+72 W »¤» Faris AND AFFIDAVIT
Defendant(s)
CASE NUMBER: V ,
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I, J < declare that I am the (check appropriate box)
in the above—entitled proceeding; that in support of my request to proceed without prepayrn O·j·i'''..Y `'O``
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that am K»A~- .... - ..,s.s. t g
sought in the complaint/petitior./motion. p
2
In support of this application, I answer the follo ng uestions under penalty of perjury:
1. Are you currently incarcerated? ° w • •NO (If"N0" 30 to ‘l"‘· ·•=’ ,as_;,,,
If "YES" state the place of your incarceration KZ EIFILJFI/dt} CEI/é£rZl€7' ”"l’°'r CBN; lb/JE
Inmate Identification Number (Required): ZG { `D·(Z>
Are you employed at the institution'? Do you receive any payment from the institution? [QD
Attach tr Ire:/ver sheet from the instittttiorz of voor income:-atiort slrou-·r'n¤, at least the gas: stir moat/ts'
transactions
2. Are you currently employed? ° °§'-es °@ i
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 of your employer. ·
ga? lf 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 I2 twelve months have you received any money from any of the following sources? .
» a. Business, profession or other self-employment · · Yes
b. Rentpayrnents, interest or dividends · • Yes •·•···N"6'
c. Pensions, annuities or life insurance payments · · Yes ·yl'~T{
d. Disability or workers compensation payments · · Yes ·,vN’<(
e. Gifts or inherirances • · Yes ·-•’NcT{
t`. Any other sources · · Yes
lf the answer to any ofthe above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.

. Case 1:06-cv—00715-SLR Document 1 Filed 11/29/2006 Page 2 of 2
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4. y Do you have any cash or checking or savings accounts? · • Yes ‘ ;,N(
If "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
i • • Yes · ;j>l·s/{
If "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 if applicable.
ji/0 rt}!
I declareunder penalty of peij ury that the above infomation is true and correct.

ATE GNAT F 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 certiiied
statement ofeach account.

Case 1:06-cv-00715-SLR Document 1-2 Filed 11/29/2006 Page 1 of 1
DELA WARE C ORRE C T I ONAL CENTER
SUPPORT SER VI CES OFFICE
MEMORANDUM
TO: r A A sEt#.- O'? O {Q1 E
· ate Kim;
FROM: Stacy Shane, Sttpp0rtSen»t'ces Secretary N O 6 _ 7 1 5 as
RE: · in .1c_1.., t cyy. A ccy_.1._c. A .1cc 1 .11,_ccc A, A
. EE-EEE U
DA I E { [ `,.. -.1;1 T .__. A,. .,V,·.
‘ NEW ZUUE
Attached are ccpies cfyeur inmate account staternentfc ·:~e·» ·=-·-= FE
to
T he following indicates the avenage daily balances.
MONTH AVERAGE DAILYBALANCE
A E SQ

5g
/.0;
A t QZ g
Average daily balances/6 manths: 05-/
Attachments
cc; File %H_L,_b2
Eflil/X~€} HA A/tc
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