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

Case 1:05-cv—OO763-Gl\/IS Document 1 Filed 11/O2/2005 Page 1 of 2
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Plaintiff im "`ii L ‘*;·~ s -_g;e———-MEELIQATION TO PROCEED
i '__, __ ·' . ` WITHDUT PRIEPAYMENT OF
V. W AND /yFl·IDAVIT O 5 _ 7 6 3
4 J - · ‘ ,4 _ _ . . .
Det`endant(s) I . I =· jiAbl;§NUi~/IBER.
I - >-·-.r____ ______ I
i it li lll? hifi liri·i]i"—` i
k ,. _lilF*`i:-ill" wi: pri .-`~_lTA,l; Z _ , I _ . _ _.
I, Ot 1 O\lm·L 4 -· -;:1 ·. __ ic · declare that I am me (check appropriate box;
Ni Petitioner/Plaintifi}’Movant E Other in the al>ove—entitled proceeding; that in support ofmy
request to proceed without prepayment ofiecs or costs under 23 USC §l9l5, I declare thati am
unable to pay the costs otthese proceedings and that I am entitled to the relicfsouglit in the
complaint/petition/motion.
In support ofthis application, I answer the following questions under penalty of perjury;
I. Are you currently incarcerated? |jYes D No (If "l\io" go to Question 2)
If "YES" state the place ofyour incarceration Q)¤<_iQ,,L;;i,y—i` Co l"‘|*”{-.(L.`ilOY\Qi [i;—¥—V`*li-Q in (© it Qi `pacicic>LK Read
Are you employed at the institution? dYes U No élmtiy- hq; Qeiawayi j‘¥] Do you receive any payment from the institution'? lS(Yes [I No
Hove tfie institiizion [if! out {/ie certificate riiorfion 0[ tiiis c:f`[ira'ai¤it giizdrztrrzch ri Zedver siiee! {r·o.»ig_&i;
iristitiirioiiisl 0{ your Inca:-·cei·¤tioiz showirzv ri! Ierist the post .S'i’Xmoizr}is' tr·mi.mc·i‘ir}ii.v. Lerlger
&Q§_Gre not required for cases {tied r2z:i·sttr2m‘ I0 28.* USC §2254. :
2. Are you currently employed? I§(‘Yes Cl No
a. Ifthe answer is "YES" state the amount of your take·home salary or wagesand pay period and
give the name and address of your employer. pr ppro X t.U¤’\0ln‘i'i'i
b. Ifthe answer is "NO" state the date ofyour last employment, the amount of your take-home
salary or wages and pay period and the name and address of your last employer.
3. In the past I2 twelve months have you received any money from any ofthe following sources?
y a. Business, profession or other self-employment I] Yes lj No
b. Rent payments, interest or dividends [I Yes FEI/No
c. ' Pensions, annuities or life insurance payments I] Yes lEitNo
d. Disability or workers compensation payments lil Yes dhlo _
e. Gifts or inheritences Cl Yes [irifhio
t`. Any other sources D Yes EI/No M
if the answer to any of the above is "YES" describe each source oi` money and state the amount
received AND what you expeet you will continue to receive.

Case 1:05-cv—OO763-Gl\/IS Document 1 Filed 11/O2/2005 Page 2 of 2
L 4. Do you have any cash or checking or savings accounts`? [I Yes K?{No
lf "Yes" state the total amount S ®
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or
other valuable property? Cl Yes Q/No
If"Yes" describe the property and state its value. N/p,
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 declare under penalty otperjury that the above information is true and correct.
Date: 3) ,QOO; Signanire ofikpplicantg