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


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Pages: 2
Date: September 19, 2005
File Format: PDF
State: Delaware
Category: District Court of Delaware
Author: unknown
Word Count: 539 Words, 3,538 Characters
Page Size: Letter (8 1/2" x 11")
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https://www.findforms.com/pdf_files/ded/35473/1-1.pdf

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_ Case 1:05-cv-00679-JJF Document 1 Filed O9/16/2005 Page 1 of 2
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
[ - Q s z ti h
1=· atmtrr APPLICATION TO PROCEED
5 V. 4 g WITHOUT PREPAYMQT OF
tk • -- . .,.4 FEES AND AF FIDA [F 6 T g
`M Defendan s) l I r 5
CASE NUMBER:
I, L Gi A.: .. Q t declare that I am the (check appropriate box)
° ° Petitioner nu ··· ovant ° ° Other
inthe above-entitled proceeding; that in support of my request to proceed without prepay nt of ‘’‘ ' ``' ‘ . all 2__j;` E
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that am = 1*
sought in the complaintfpetitionlmotion.
In support of this application, I answer the following questions under penalty of perjury: _ _ _ __
l. Are you currently incarcerated? ° ° °No (lf "No" go to Qu tion g
If “YES" state the place of your incarceration SX p l 1
Inmate Identification Number (Required): _ A [ Q
Are you employed at the institution? Do you receive any payment from the institution?
A Mach a ledger sheet [rom the inmttalion o{ your incarceration showing at least the gas! sb: montl1s'
trarzsaclions
2. Are you currently employed? ° ° Yes °
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.
b. If the answer is "NO" state the date of your last employment, the amount of your _:_.tr j§ ,• so
salary or wages and pay period and the name and address of your last employer. _
3. In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment · · Yes
b. Rent payments, interest or dividends • · Yes
c. Pensions, annuities or life insurance payments • · Yes
d. Disability or workers compensation payments · · Yes
e. Gifts or inhcritanoes • • Yes
f. Any other sources · • Yes
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-00679-JJF Document 1 Filed O9/16/2005 Page 2 of 2
AO 240 R r 1U,·'fX3)
DELAWA A U5
4. D0 you have any cash or checking or savings co unts? · • Yes _ \ _
If "Yes" state the total amount S {
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
•·Yes ·__W
If "Yes" describe the property and state its value.
/
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 that tl · - ove inf mation is true and correct.
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 certified 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 certified
statement of each account.