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


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Date: April 3, 2006
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State: Delaware
Category: District Court of Delaware
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Case 1 :0 -cv-00 18-KAJ Docum nt 1 . Filed 03/31/2006 Pa e 1 of
Search — 21 Results -qiead1ng%pauper1s) or sectiongnaupems) g Algage 1 of 5
Source; ` > > > , > > Bender's Federal
Practice Forms -
TOC: > > > 54:452 Affidavit in Support of
Motion for Waiver of Fees --Exemplar of Court-Supplied Form 1
Terms: heading(pauperis) or section(pauperis) ( I )
{Select for FOCUSIM or Delivery
6-54 Bender's Federal Practice Forms Form 54:452 N
Bender's Federal Practice Forms
Copyright 2006, Matthew Bender & Company, Inc., a member of the LexisNexis Group.
FEDERAL RULES OF CIVIL PROCEDURE
54 Judgments; Costs E D
FORMS I ` _`_` ,)
In Forma Pauperis Actions I ULTEEQOURT
‘ I FHCTGF ·`iE` `
6-54 Bender's Federal Practice Forms Form 54: , IJ WARE
{Tal;) 5 :111 FUN? t {
Form 54:452 Affidavit in Support of Motion for Waiver of Fees --Exemp|ar of Court-
Supplied Form 1
[Caption. Form No. 54:450]
AFFIDAVIT OF‘ lg.-{gag, j L/»;{[_S,,»5»{NAME OF AFFIANT]
I, },;>. gg; 9 [ni, .".§;,2·iJ[name], make under oath the following statement regarding my
financial, residential, marital, and status, and since I am unable to prepay fees
and costs in the above-entitled , make application to proceed as a pauper in accordance
with
A. BACKGROUND AND RESIDENCE
1. Full Name: [-2€¤~ (4;,; JQ-),. lf; C-af 2.::****}
2. Age: Lf- if Sex: Ars 4 jc?
_ _ _, ~ ,-y ' _‘__ __ .f M F `?’ L: was · My
3. Present Address: ig ci Lp Ll/U limo-’ £»*`Li·¤’5` F"-A 5 1; if an
Dcilq no-‘ .<-< •" fi / "i ji 3 tf
4. How long at this address? Q @ ;. M-'T L\ J Phone l\lo.
A.? wl,. vi gid-- *· {Q C, 6* ,
( _>L%).%+;_g@ , //
5. Married? Single? ·'
Divorced? Separated?
6. Number of dependents: gc ( C
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E 7;% Ages of children living with you:
8. List relationships of other dependents living with you:
9. List any dependents in items 7 and 8 depending on you for support:
B. EMPLOYMENT AND INCOME
1. Are you now employed? Are you self-employed?
2. Name and address of employer:
3. Position: Salary per month: $
4. If se|f—emp|oyed, nature of :
5. Income previous month from se|f—employment? $
6. If unemploye_d, how long since last or se|f—employment?
I 2 is A ’f· S
7. Any other income, such as disability pay, workers' compensation, social
security, pension interests, note andloan repayments, dividends, trust funds,
unemployment compensation? $ [ [Oc?. 4.*,;*
8. If so, indicate source and amount per month'/gl 100. .49.4* Z /\·`\17’/J T A
9. Total monthly net income: $ if fp 6/ .- 5,;* 5 J;. »..:,/ S 5,, ,`- lL 5/
C. ASSETS
1. Do you own any real estate? Yes
a. Description
b. Location
c. Estimated present value $
d. Estimated outstanding mortgages or contracts on property $
e. Payments per month $
2. Do you own any automobiles: @1 No
I i__ 1- I
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I a. Make 2* I? ir! Model pi 1. Zz E . [J Year
b. Present Value $ l 267 6* gi;) Total amount owed $
c. Monthly payments $ , , [J C?
3. Do you have any stocks or bonds? Yes ( l\loH)
a. Describe
b. Present value $
Ax
4. Do you have any cash in the banl a. If so, indicate amount $ gc 5 L7
5. Do you have any ca llin savings and loan associations? Yes
—
a. If so, indicate amount $
6. Do you any other assets not Iiste Qove, excluding household furnishings and
clothing? Yes No ‘
a. If so, describe and give value
D. DEBTS AND OTHER OBLIGATIONS
1. Rent $ fz { l-(-2 0 Cj per month
2. Utilities $ ':_5Cl(.»‘ , 0;.) goer month 7 Ll Q [Lrg!] Q
3. Creditors: L-; il L’6·'f*/fp T;) il JY? 5 rm L) nj _
List: T‘c.>raQ Di:0 E‘~·f;vr.T.liQy Payrtmni
3 _ $ _ $ _
_ 5 _ $ _
5 _ S _
3 3 $ 3 *‘ .-
_ $ $ _
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S S _
. $ _ $ _
S S _
4. Total Monthly Payments: $ [ Q rf-ii}
, rr"? F A
Signature of Applicant/Affiant
` {fi 2, ("| J. ,
i(/ tg, qq/·y\,,t,g.» .· {/-C—·L_ft/.4...7)-J) 1-*/
5 JEL
?U,l3SCRIBED AND SWORN to before me this ·— yé day of
5-fzia-{E ( ···. 7 [moriffvyear].
( { Q ,*-4, 295 @--*7, , _
l\lotary Public <
CMCLI; A. FEL.i·C='?
Nr-t:.:y Public, Kent County, Delevvare
:.· ,· Camrniseion Expires April O3, EGGS
My Commission Expires:
ORDER
The Court has considered the foregoing Affidavit and Application and the same is DENIED.
or
The Court has considered the foregoing Affidavit and Application and the same is GRANTED.
It is ordered that the commencement and prosecution of the above—entit|ed suit, action, or
proceeding is authorized without the prepayment of the filing fee, costs, or security therefor.
However, any further proceedings involving costs may be specifically authorized in advance
by the Court.
DONE at [c/ty, state] this day of
[month, year].
United States Magistrate Judge
1. This form was adapted from Form SF-010, District Court for the District of New Mexico.
Many local rules require that parties use forms of affidavits supplied by the court. See, e.g.,
Local Rules, N.D. Cal., L.R. 3-10 ("affidavit or declaration under penalty of perjury providing
the information required by Title on a form available at the Office of the
Clerk and on the Court's Internet site, or an equivalent form"); Local Rules, N.D. III., L.R. 3.3
(a)(2) (financial affidavit "prescribed by the Court"); Local Rules, N.D. Miss, Form P3
(prisoner's affidavit). There is also a mandatory form for use in the United States Courts of
Appeals. See Official Form 4 of the Appendix of Forms to the Federal Rules of Appellate
Procedure (set out in this book as Form No. AR24:1). Many trial courts are also using that
form of affidavit.
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