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

Case 1 :06-cv-00152-JJF Document 5 Filed 04/19/2006 Page 1 of 3
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AO 24C|(Rev.I0/03] VL In {4 I} &
DELAWARE {Rev. QUE] Q}
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Piaimirr APPLICATION TO PROCEED V
V._ _ WITHOUT PREPAYMENT OF
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D fendant(s) · » J"
CASE NUMBER; ···· K /4
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I, ___ é 24%/' Q5 fc (J Q FJZQYY 6 declare that I am the (check appropriate box)
E/ PetitionerfPlaintiff/Movant El Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §I9l5, I declare that I amunable to pay the costs of these proceedings and .r..r . ...t.. ` = s . ar e i .vs... ME
sought in the complaintfpetitionfmotion. § Q
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In support of this application, I answer the fol questions under penalty of peiju ; Milf l ij g
I 1. Are you currently incarcerated? Yes El No (lf "No" goto uesti ww ,,,__ pw,. CDU T
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If "YES" state the place of your incarceration { d Gi ' tr » & i‘`‘1‘‘‘‘`‘‘ " "
Inmate Identification Number (Required): / 5 2
Are you employed at the institution? Ag Q Do you receive any payment from the institution? /\/ip
Attach a iedger sheet from the institution ot your incarceration showing at least the gust sir months '
trcznsactions
2. Are you currently employed? D Yes M
a. If the answer is "YES" state the amount of your take—home salary or wages and pay period a
and give the name mid address of your employer. ,/Ft
h. If the answer is "NO" state the date of your last employment, the amount of your tak?—home
salary or wages and pay period and the name and address of your last employerj;1 P4/6
been an SSD; 5/mae /‘?5,.2
3. In the past 12 twelve months have you received any money from any of the following sources'?
a. Business, profession or other self—employment D Yes No
b. Rent payments, interest or dividends El Yes No
c. Pensions, annuities or life insurance payments El Yes No
d. Disability or workers compensation payments E'! Yes No
e. Gifts or inheritances U Yes No
f. Any other sources U Yes No
If the answer to any of the above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive. 55Djf ceaébf-
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Case 1 :06-cv-00152-JJF Document 5 Filed O4/19/2006 Page 2 of 3
AO 240 Reverse {Rev. 1(UD3]
DELAWARE Rev. 4C[l5l
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4. Do you have any cash or chec ng or savings accounts? . — ’ Yes El No
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If "Yes" state the total amount $ .6 -{F5'? gi, 005} ··· L; E . , Qwjjméwl '_ _
5. Do you own any real estate, stocks, bonds, securities, other itinancial instruments, automobiles or other
valuable property? ..
1:1 Yes ufbg
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.
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I declare mder penalty of perjury that the above information is true and correct.
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DATE SIGNATURE OF 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 certified
statement of each account.

Case 1 :06-cv-00152-JJF Document 5 Filed 04/19/2006 Page 3 0f 3
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