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

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A Case 1 :05-cv-00763-GIVIS Document 19 Filed 03/13/2008 t Pa€g»e—¢1—erf~%··*·r""‘""“"’“ `'‘` t
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. AO 240(Rev. 10,/05) I E , I
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DISTRICT OF DELAWARE .
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Piatautr APPLICATION TO PROCEED
> v. ‘ _ WITHOUT PREPAYMENT OF
[ iigigmg is L · Qgrro ff FEES AND AFFIDAVIT
_ Defendant(s)‘ CA O S-· 3
r I I C CASE NUMBER: ii
I, EQ; tj g' Wg Q I 19 [ declare that I am the (check appropriate box) ,
°§Q° Fetitioner/Plaintiff/`Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under p
. 28 USC §l9l5, Ideclare that I am unable to pay the costs of these proceedings and that I am entitled to the relief `·
sought in the cornplainblpetition/motion.
In support of this application, I answer the following questions under penalty of perjury: I _
i 1, Are you currently incarcerated? °`l&°{es ° °No {If "No" goto Question 2)
i if "YES" state the place of your incarceration QA)? »;Lp4_j cl_t"§ ClCDt·”t"Ej,[)iI Oi') LJ ~
1 Inmate Idenriiication Number (Required); C-? 5 la A
I Are you employed at the institution? c. Do you receive any payment from the institution? KJ} i
Attach ci ledger sheet from t/ie instittttiort of vow fricarcemtion s}t0w1'ncr at [east t/ie ggrtst silt mont/is'
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A 2. Are you currently employed? °\A° Yes ° No in i
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a
{ and give the name and address of your employer. _ E i i {
b. lf 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. _
3. ln the past 12 twelve months have you received any money from any of the following sources? .
4 a. Business, profession or other self-employment · • Yes N No
· b. Rent payments, interest or dividends I ' • YeS •)(• No
c. Pensions, annuities or life insurance payments · · Yes No .
d. Disability or workers compensation payments · · Yes hb No
e. Gifts or inheritances - · · Yes ·)€· No
f. Any other sources · · Yes No
lf 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-00763-GIVIS Document 19 Filed 03/13/2008 Page 2 of 2
AO 1-ll) Reverse (Rev, 10,*03)
DEl,.1.WAREfRev. 4/U5! . `
4. Do you have any cash or checking or savings accounts? • · Yes %No
I If "Yes" state the total amount S I
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
’ ·· valuable property? ·-
1 • · Yes ·lQNo
If "Yes" describe the property and state its value.
i 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 I declare under penalty ofpeigury that the above infomation is tme and correct. :
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DATE I · IGNATURE OF APPLICANT I ·
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 lastsix 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.