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

_ Case 1:O5—cv-00576-JJF Document 51 Filed O9/O1/2006 Page 1 of 3
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DELAWARE (Rev. 4t05l
I UNITED STATES DISTRICT COURT
I · » . DISTRI T OF DELAWARE
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( piaintsrtg; ’ APPLICATION TO PROCEED
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time VF-]-Vi tv!/{A¤;,‘€b ;
Orme/, @{4, (sg /View/E FEES AND AFFIDAVIT
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I, th/il//t·tt*» fp it/6*% UK i 00256 05% declare that I am the (check appropriate box)
° ° Petitione ovant ° ° Other N eg
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in the above-entitled proceeding; that in suppon of my request to proceed without prepayment of feegqr cqsiisginder
28 USC §I9I5, I declare that I am unable to pay the costs ofthese proceedings and that I am entitI’62I to Q€te,»reYl1iet`
sought in th petition/motion. _L QQ;}->
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In support ofthis application, I answer the follow'ng questions under penalty of perj ury: cio
I. Are you currently incarcerated? ° °No (If"l\lo" goto Question 2)
_ If "YES" state the place ofyour incarceration Ofjiile/g/"° (O//€’ I
Inmate Identification Number (Required):
Are you employed at the institution?/if/O Do you receive any payment from the institution?
Attach a ledger sheet Qorn the institution ot your incarceration showing at least the Qast sbc months'
transactions /`
2. Are you currently employed? ° ° Yes
a. Ifthe answer is "YES" state the amount ofyour take-home salary or wages and pay period a
` and give the name and address of your employer.
b. Ifthe answer is "NO" state the date of your last employment, the amount ofyour tal sahtry or wages and pay period and the name4 and address ofyour last employer. V Ex;/ft—:»/j;,( il;
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3. In the past I2 twelv montlis have’you received any money fromén ofthe follo ing sources? ( A Q;
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a. Business, profession or other self-employment · • Yes l ///
b. Rent payments, interest or dividends · • Yes L4 •
c. Pensions, annuities or life insurance payments · · Yes
d. Disability or workers compensation payments • • Yes p No
e. Gifts or inheritances < ·rL/Ye§ • •
f. Any other sources · · Yes -6 No
Ifthe answer to any ofthe above is "YES" describe each source ofmoney and state the amount
V received AND what you expect you will continue to receive.
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Case 1 :05-cv-00576-JJF Document 51 Filed O9/O1/2006 Page 2 of 3
AO 240 Reverse (Rev. I0/03)
DELAWARE Rev. 4{05]
4. Do you have any cash or checking or savings accounts? • • Yes
lf "Yes" state the total amount $5
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? /
· · Yes No
If "Yes" describe the property and state its value.
)l 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 of perjury that the above information is true and correct.
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ATE 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 lastsix months in your institutional accounts.
If` you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement ofeach account.

Case 1 :05-cv-00576-JJF Document 51 Filed O9/O1/2006 Page 3 of 3
. CERTIFICATE
T (incarcerated applicants only)
(T0 be comp/clad bv the instilulion of incarceration)
I certify that the applicant named herein has the sum of$ O on account his/her credit at (name
ofinstitutiori) AQg@é£yz l further certify that the applicant has the following securities to his/her credit;
All /·l .
I further certify that during the past six months the applicant's average monthly balance was $ Ii Lf
and the average monthly deposits were S Z TU 7
;2[Q3l0(¤ Qécégl d
Date Signature ofAuthorized Officer
(NOTE THE REQUIREMENTIN ITEMI FOR THE INMATE TO OBTAIN AND ATTACH LEDGER
SHEETS OFACCOUNT TRANSACTIONS OVER THE PAST SIX MONTH PERIOD. LEDGER SHEETS
ARE NOT REQUIRED FOR CASES FILED PURSUANT TO 28: USC §2254)
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