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

Case 1:05-cv-00813-SLR Document 1 Filed 11/28/2005 Page 1 of 2
AOB-10 (Rev, 10/O"!]
Dl;.LA\‘.`,·\KE. (Rev, 4/05
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
L/Z Ul/» Dri (/LS
Plaintiff APPLICATION TO PROCEED
w V. _ WITHOUT PREPAYMENT OF
- Ht? 72 C?/Ci ` :24// (..5 FEES AND AF F IDAVIT
Defendant(s)
CASE NUMBER: O 5 __ 8 1 3
I, Lg?/2/Zi? WS declare that I ain the (check appropriate box)
Ei Petitioner/Plaintifffl\/Iovant Ei 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 thatI am unable to pay the costs ofthese proceedings and that I am entitled to the relief
sought in the complaint/petition/motion. as
In support ofthis application, I answer the following questions under penalty of perjury: ` _
I. Are you currently incarcerated? D Yes E No (If"No" go to Question 2) CJ _ . -
If "YES" state the place of your incarceration
Us .
Inmate Identification Number (Required): V9 I
Are you employed at the institution? N D Do you receive any payment from the institution? hi O
A/toc/1 ti Iedg er sheet Qoni the institution of your incarceration showing at least the Q ost six mont/is'
lrcriisrrctions
2. Are you currently employed? E Yes KNO
a. If the answer is "YES" state the amount of your take—ho.me salary or wages and pay period a
and give the name and address of your employer.
b. If the answer is "NO" state the date of your last employment, the amount ofyour tal salar or wages and pay period and the name nd address of yo last employer. .
5 ,./i -g, f mgm ,, r,;_sc>.>»g¢a·4 $ in/C l;l5iH.§V:;;L_.,__.é.i+ /'li't|gl'4`iE.»§>eaC_¤§;f_€4 1?1&_ { UL
7 JL l ' 1 (fl,
3. In the past 12 twelve months have you received any money from any ofthe following sources? UT:} Q 4;,2,
a. Business, profession or other self—employment El Yes ¤/ No
b. Rent payments, interest or dividends El Yes 12/No
c. Pensions, annuities or life insurance payments El Yes tg/No
d. Disability or workers compensation payments U Yes No
e. Gifts or inheritances D Yes we
f. Any other sources El 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-00813-SLR Document 1 Filed 11/28/2005 Page 2 of 2
AO 240 Reverse (Rev. I0/0])
Dl;Lt·\\\'.-\RE Rev. 4/UF
4. Do you have any cash or checking or savings accounts? Cl Yes Eélo
lf "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? J
Yes El No
If "Yes" describe the property and state its value. _ A) _
’ ._ ,; _ rec M,. ‘» » .
HUYWAT 0):6lgL N 3* gdk Llgqug l;;,icf;g`- /¢{·$¤~?`(%Z°?O/M‘C·
ll`°5°`f‘l“°"lJ`“ {LG _ W Ybjgrno. 0-0
ici _ gcc; p LC Qawteq L__T LLL/(aoL¢·w.
· - "O Q>c;,·¤.»
}».|.,C[l\ mr @3.;., j_£.. _.€
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. _ . _
/\/ 0J\l 5
I declare under penalty of perjury that the above infomation is true and correct.
_..,
my - AM ,42/ ,
,2 X C5 , -;’?2f-·£-u”Z/ rf {J (jguxg
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 certiiied 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.