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

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AD 240 {Rev-. ID/D3)
DELAWARE {RE.
IUNITED STATES DISTRICT COURT
DISTRICT OF DELAI?VAIm I S
Lisa Dggjg I
‘ rmnurr APPLICATION T0 I>ROCEEI)
V. WITHOUT PREPAYMENT OF
Hgaullgugh S, mgmt: .,2 tho and » mma L_ FEES AND AFFIDAVIT
Defendant(s) Hckeuty
CASE NUMBER:
L Lisa Davis declare that 1 am the (check appropriate box)
B Petitioner/Plaintift7Movant Cl Other
in the aboveentitted proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC § 1915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, 1 answer the following questions under penalty of perjury:
1. Are you currently incarcerated? D Yes H No (If "No" go to Question 2)
lf “YES" state the place of your incarceration
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution? m
Attach a ledger sheet [rom the in.s·ri.t:,z:.€:::: of ;,·::;::· iaesrserazicx r.=k»ow£::g at Ions! she ,;a,s! six month.? '
transactions .
2. Axe you currently employed? Yes · EN0 . 4
a. If the answer is "YES" state the amount of your take-home salauy or wages and pay period a
and give the name and address of your employer.
b. lfthe answer is "N()" state the date of your last. employment, the amount of y¤¤t' t¤k¤·h¤I¤¤
salary or wages and pay period and the name and address otiyour last employer.
9 In the past 12 twelve months have you received any money from any of the following sources?
I a. Business, profession or other selfemploymcnt Et Yes $5 No
b. Rent payments, interest or dividends ¤ Yes Im No
c, Pensions, annuities or life insurance payments D Yes IS); No
d. Disability or workers compensation payments xg Yes I;. No
e. Gifts or inheritanees ¤ Yes gr No
tl Any other sources in Yes is}; No
lf the 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. . ·
$520 per month SSI-

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` > Do you have any cash or cheeldng or savings accounts? 1:1 Yes )z¢`Ne
If "Yes“ state the total amount $
{ > Do you ovlm any real estate, stocks, bonds, securities, other Hnancial instruments, automobiles or other
valuable property? 5
CI Yes X; No
1i"'Yes" describe the property and state its value.
{ 6. > List Qt: persons who w 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.
{\ ¤v\ & A
I declare under penalty of perjury that the above intbrrnation is true and correct.
‘?\l<>1¤l$ tvs l
DATE SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shalt submit an aliidavirr
staring all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
ofiicer 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 certined
statement of each account. 4 .

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·s.·.c ma (nu. mn _ _
UNITED STATES DISTRICT COURT 4
District of E] umm
-“““ °“"1“ ORDER ON APPLICATION
Plaintiff TO PROCEED WITHOUT
V PREPAYMENT OF FEES
McCullough and liclcnty, ]?.A. - p "
and Daniel. L- _____,_ ___i _,_, _ _ W r_rr r___)i niiiiy
Defendant
Having considered the application to proceed without prepayment of fees under 28 USC § 1915;
IT IS ORDERED that the application is:
D GRANTED- F
[3 The clerk is directed to file the complaint.
EI lT 1S FURTHER ORDERED that the clerk issue summons and the United States marshal serve a
copy of the complaint, summons and this order upon the defendant(s) as directed by the plaintiff.
All costs of service shall he advanced by the United States-
EI DENIED, for the following reasons:
ENTER this day of , .
Signature of Judicial Officer
Name ima Title or Judicial oniger F F