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

n Case 1 :05-cv-00684-*** Document 26 Filed 08/23/2006 Page 1 of 2
i ”—`zaA0 240 (Rev. 10/03)
UNITED STATES DISTRICT COURT
District of Delaware
PHILLIP ALLEN DYE, Debtor, phillip allen dye
Private Secure Party, Creditor APPLICATION T0 PRQCEED
Plaintiff WITHOUT PREPAYMENT OF
V FEES AND AFF IDAVIT
` · B 5
MICHAEL B. JOSEPH, TRUSTEE if
CASENUMEE11: $ E in " I X
Defendant ‘ ‘ ‘· I O *· · A-
1, Phillip allen dye declare that I am the (c eek prdl§i&tE
» T i
IZIpetitioner/plaintiff/movant EI other ? i I . _.. . . at , ;, Y
_ _ _ _ _ r U.S. DlSTl;ttCT COURT l l 9
in the above—entitled proceedmg; that m support of my request to proceed without an _• not ARE g
under 28 USC §I9l5 I declare that I am unable to pay the costs of these proceedings and that I am entit l i to '``O ` A
relief sought in the complaint./petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? lj Yes m No (If “No," go to Part 2)
If "Yes," state the place of your incarceration
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months’
transactions.
2. Are you currently employed? lj Yes E No
a. If the answer is "Yes," state the amount of your take—home salary or wages and pay period and give the
name and address of your employer. [List both gross and net salary.)
b. If 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. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employment [I Yes IZI No
b. Rent payments, interest or dividends Yes IZI No
c. Pensions, annuities or life insurance payments El Yes IZINo
d. Disability or workers compensation payments El Yes [INo
e. Gifts or inheritances I] Yes E No
f. Any other sources I] Yes E No
If the answer to any of the above- is "Ye-s," describe, on the following page, each source of money and state the
amount received and what you expect you will continue to receive.

Case 1 :05-cv-00684-*** Document 26 Filed 08/23/2006 Page 2 of 2
R AO 240 Reverse (Rev. I0/03)
3 (g). The offer of Tender ot Payment tor Filing Fees is attached, Statement ot Assignment of
Account.
4. Do you have any cash or checking or savings accounts? [I Yes IZINo
If"Yes," state the total amount.
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
thing of value? I] Yes E No
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. (If children are dependents, please refer to them by their initials)
I declare under penalty of peijury that the above information is true and correct-
August 21, 2006 ata., ww
Date Signature of Applicant
NOTICE 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.