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

t, pl Case 1:05-cv—00783-Gl\/IS Document 1 Filed 11/10/2005 Page 1 of 2 _
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. · I? ·· ‘‘‘‘ """"‘“"i; it APPLICATION TO PROCEED ·
_ _ Plaintiff p _, , O _., . T ` WITHOUT PREPAYMENT OF _
_ Q V ,) ’t*I ‘ “ ` `J ‘ ET 1,__ F EES AND AFFIDAVIT. A d
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n Defendant _ ‘ g · t , _ ___: _ .
;_. t T let; slr 4; | lat tc oltacl ‘ i/\‘—-M—*ti,lL¤- ~ declare that I am the (check appropriate box)
petitioner/plaindif/movmtt A _ i El other . n _ _ _
in the above—entitled proceeding; that in support of my request toproceed withoutprepayment of fees or costs
under 23 USC 51915 I declare that I am unable to pay the costs of these proceedings and that I am entitled- to the relic
sought in the complaint/petition/motion. _ i .
In support of this application, I answer the following questions under penalty of perjury; _ _
, 1. Are you currently incarcerated? _`$YBS‘ at (__ D NQ _ - _ [If i`No," go to_Part 2) __ _
. If "Yes," state the place ofyvuf ii1¢¤1’¤¢1‘¤¥iQ`¤
- ; Are you employed at the institution? ’g" Do you receiye any payment from the institution?
Attach a ledger sheet from the institutionfs) of your incarceration showing at least the past six months’ n
. transactions, l ·“ »‘ ‘_ - _- _· .-
2. Are you currently employed? - Yes aééo ` O . · , _ `
- ` - _a_ Ifthe arrswertis “Yes, * state the amount of your take-home salary or wages and pay period and give the name `
T and address of your employer. ‘ ` . , _ - ,
- b. - if the answer is “No,” state the date of your last employntentrthe amount of your takeghome salary or wages
and payperiod and the name andgadgress of your last` employer. i ._ _ 1 _l· ‘ _ ' _
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3.. In the past 12gtwelve rnonths`h'ave you received any money from any of the following sources? · n
a. Business, profession or other self-employment El Yes ,·Ei‘No ‘
p· b. ·Rent payments, interest or dividends _ _ ‘ lj Yes _ . _ ,EiNo ·
c. Pensions, annuities or life insurance payments . El Yes ‘ __;E=’No T
d. Disability or workers compensation payments - El Yes · ;BN0
i , e. Gifts or inheritances El Yes _.E7\lo
f. Any other sources ‘ - Yes t ,.E’l' If the answer to any of the above is "Yes," describe, 011 the f0il0Wing page, eachsource of moneyand state the
amount received and what you expect you will continue to receive. ‘- . _

6 Case 1 :05-cv—OO783-GIVIS Document 1 Filed 11/10/2005 Page 2 of 2
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4. Do you have any cash or checking or savings accounts? I D Yes Z ‘ E'No g n
_If `"Yes,” state the total arnount. _ up - e n n
_ 5. Do you own any real estate, stocks, bonds. s -rities, other financial instruments. automobiles 0 l tj;
thing ofvalue? ClYes p` ' mi, . ` i ` ‘ r ranyc {
If “Yes," describe the property and state its value, n ` e n g n
t-;_ List the person; who are dependent on you for support. state your relationship to each person and indjcjatg
_ · how rnuch you contribute to their support. · g _ ‘ ‘ _ g . `
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I declare under penalty of perjury that the above information is true and correct, I I _ [ _
I { /_ i i --~;<#:·;2 ‘ one —
NOTICE T0 PRISONER; A Prisoner seeking to proceed without prepayment of fees shall submit an aitidarrtt
stating an asset; In addition-, a prisoner must attach a statement certified by th appropriate instituttcnatufticer
showing all receipts, expenditures, and balances dllfillg the last Six months in your institutional accgume Ifyou have
multiple accounts, perhaps because you have been in multipleinstitutions, attach one certified statement. of Bach
account. . · ‘ ~ ` ‘ l .