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

Case 1 :05-cv-00570-KAJ Document 1 Filed 08/O4/2005 Page 1 of 2 i
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UNITED STATES DISTRICT COURT
- DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
_\ V. * WITHOUT PREPAYIVIENT OF
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I, _ A Q .. . /+5 iQ l MS JK declare that I am the (check appropriate box)
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in the above-entitled proceeding; that in support of my request to proceed without prep yme a -@der—, l
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and at I m entitled to the relief
sought in the complaint/petition/motion. e W4. e
In support of this application, I answer the following questions under penalty of perj ; Ul . ? I I.
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l. Are you currently incarcerated? @ ° °N0 (If "N0" go to Question 2)
If "YES" state the place of your incarceration lid to had You oaf 7:-u4’7'£
- Inmate Identification Number (Required): Q; ll O .g
Are you employed at the institution? Do you receive any payment from the institution? L J é A
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast six months ’
transactions
2. Are you currently employed? ° ° Yes
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. Ifthe 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 l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment • • Yes * 0
b. Rent payments, interest or dividends • • Yes • • N yl
c. Pensions, annuities or life insurance payments • • Yes
d. Disability or workers compensation payments • • Yes • No ‘
e. Gifts or inheritances • • Yes • Noi .
f. Any other sources • • Yes • • No
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-00570-KAJ Document 1 Filed 08/O4/2005 Page 2 of 2
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4. Do you have any cash or checking or savings accounts? tglef • •No
If "Yes" state the total amount s/Ct ict C ’C.·
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
valuable property? P é
_ • • Yes Cgi?)
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.
Mat/té
I declare under penalty of perjury that the above infopnation is true and correcti
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DATE — SIGNATURE OF APPLICANT s
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.