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

lg . Case 1 :05-cv-00626-JJF Document 5 Filed O9/28/2005 Page 1 of 3 -
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i. UNITED STATES DISTRICT COURT
i DISTRICT OF DELAWARE
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Ptatmtn APPLICATION T0 PROCEED
A v. WITHOUT PREPAYMENT OF
Q FEES AND AFFIDAVIT
Defendant(s) _
I I cAsE NUMBER: O9 La Qt kg
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I I, aan - \ TK? declare that I am the (check appropriate box)
i ° ° Petition= ovant ° ° Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
It 28 USC §1915, I declare that I am unable to pay the costs of these proceedings and that I . - · =· It __ - _ L
: sought in the complaintfpetition/motion. ` _ I.]
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} In support of this application, I answer the followingquestions under penalty of perjury: gg .2 8
. l. Are you currently incarcerated? ° ° °No (If "No" go to Quest' n 2) W
4 · ‘ . - U.S. DISTRICT
I _ I ~ , -·I‘ ·" TT" mists c 0 :
l If "YES" state the place of your incarceration »’,`“‘ . ’ » L · if I T F
'I Inmate Identification Number (Required): ;’/ 7
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Are you employed at the institution? M Do you receive any payment from the institution? digg} A
A Imch a ledger sheer [rom the institution 0[ your incarceration showing at lens! the gots! sit months ’
transactions ‘
2. Are you currently employed? ° ° Yes i
a. Ifthe 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 take·home
salary or wages and pa , ; e a.; .... · .·.e....• 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 • • Yes • as
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 inheritances • • Yes ·
f. Any other sources • • Yes • o.
Ifthe answer to any ofthe 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-00626-JJF Document 5 Filed O9/28/2005 Page 2 of 3 ..
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AO240Re·vene (`Rev.10/[B)
DELAWARE l .
l 4. Do you have any cash or checking or savings accounts'? • • Yes
If "Yes" state the total amount $ ’
_ i
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘
· • Yes •
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.
yr/wx/z;
‘
I declare under penalty of perjury that the above information is true and correct.
F g _, a
DATE ` { N t TU *4 F APPLIC ·;·'
NOTE T0 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.

Case1:O5—cv-00626-JJF r y ; Filed 09/28/2005 Page30f3
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