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

_ Case 1:05-cv-00791-JJF Document 1 Filed 11/15/2005 Page 1 of 2
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DISTRICT OF DELAWARE { ' i
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Plaintiff APPLICATION TO PROCEED
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Defendant(s) jd ff / * Ci ‘ QQOGL
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l, Aa arézq L :*9/‘U?*’Y6i ‘< A9 if- 2q!/iaiteclare that I am the (check appropriate box)
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l 5, l declare that l am unable to pay the costs of these proceedings and that 1 am entitled _to tl e re ief
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l. Are you currently incarcerate ?_\\_`— Yes No (lf "No" go to Question 2) I; 3-00 {
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° If "YES" state the place of gr incarceration · ,__ L_,__ ` . _· __ , J: i
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I im te Id nti eatin Number (Require ‘ ff [ 2
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Are ou cmp oyd W i sti tion'? Do you ree e any paymei 521 th? itution? Q
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Attach alcd rersheet om the institutinr 0 our incarceration showin U? least the ,a srk mo .s’ " {Vp; CQ;
transactions {/__
2. Are you cur ntly employed? El Y MNO r_ gf ·7#r7"‘
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a. If .e answer is "YES" state t amount ofyour take-home salary or wages and pay p» 1od a /0
and give the name and address of your employer. Hifi;
b. lf the answer is "NO" state the date of your last employment, the amount of your take—home @0 VL? 7T
salary or wages and pay period and the name and address of your last employer. -

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 El Yes K No
` b. Rent payments, interest or dividends El Yes )Q No
e. Pensions, annuities or life insurance payments El Yes Q No
d. Disability or workers compensation payments El Yes §L No
e. Gifts or inheritances El Yes Y No
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. /6 6 4
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Case 1:05-cv-00791-JJF Document 1 Filed 11/15/2005 Page 2 of 2
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4. Do you have any casl or checkin or saving%?;nt . p Yesxlé E1 No
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5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? · i YS
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6. List the persons who are dependent on you for support, state your relationship to each person and / if/Q
i dicat how uch you c tr`bute to hei`2»pport, OR st te NONE ifaptyzye. 5,/pf
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l declare under penalty of pe ry rat the above information is true and correct. {2//,
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NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall subm` n
affidavit stating all assets. In addition, a prisoner must attach a statement certified by the appropriatcg
institutional officer showing all receipts, expenditures, and balances during the last six months in your
institutional accounts. If you have multiple accounts, perhaps because yo ave been in multiple
institutions, attach one certified statement of each account.
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