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

Case 1 :05-cv—00844-GIVIS Document 1 Filed 12/06/2005 Page 1 of 2
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AO 24IJ (Rev. 10/03) __) QT-
DELAWARE Rev. 4 C6
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UNITED STATES DISTRICT COURT I
DISTRICT OF DELAWARE Us rrstaici aim
DI9li<|¤Qfi` at DELAWARE
ELDON T . POTTS
Piaintirr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
CHRIS SENATO, et el. FEES AND AFEIDAVIT
Defendant(s) A _ _ U,)
CASE NUMBER; ` " “‘ “
I, BLDON T - DOTT S declare that I am the (check appropriate box) i
° ° Petitionert'Plaintiff/Movarit ° ° Other
in the above—entit1ed proceeding; that in support of my request to proceed without prepayment of fes or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petitiorn'motion.
in support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? X Kes ° °No (If "No" goto Question 2)
if "YES" state the place of your incarceration SUS SEX C OREECT I ONAD TN ST I TU TT ON
- Inmate Identification Number (Required); SD I ii 2 1 J- T9 3
Are you employed at the institution? NO Do you receive any payment from the institution? JO
Attach a ledger sheet from the institution at your incarceration showing at least the past silt month!
transactions
2. Are you currently employed? ° ° Yes X° No . t
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a
l and give the name and address of your employer.
b. If 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. 1 1/ 4 / O 5
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 · · Yes • · No
b. Rent payments, interest or dividends · · Yes · · No
c. Pensions, annuities or life insurance payments • · Yes · · No
d. Disability or workers compensation payments · • Yes · • No
e. Gifts or inheritances • • Yes • · No
f. Any other sources · • 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.

Case 1 :05-cv—00844-GIVIS Document 1 Filed 12/06/2005 Page 2 of 2
AO 140 Reverse (Rev. I0/(B) I
DELAWARE (Rev. 4fO5
4. Do you have any cash or checking or savings accounts? · • Yes · ·No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
· • Yes · ·No
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.
I declare under penalty of perjury that the above infomation is true and correct.
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A 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 certiiied
statement of each account.