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

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NITED STATES DISTRICT, COURT
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®C]\l tcl él(t')@(,{/ APPLICATION TO PROCEE I
- t FORMA PAUPERIS, SUPPORTING
V- DOCUMENTATION AND ORDER {
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1, lb ' A . C A fl ` · I , declare that I am the (check appropriate box) I
W petitioner/plaintiff CI movant (filing 28 U.S.C. 2255 motion)
El respondent/defendant El l
other
in the above—entitled proceeding; that, in support of my request to proceed without being
required to prepay fees, cost or give security therefor, I state that because of my poverty, I ;
. am unable to pay the costs of said proceeding or give @urity therefor; that I believe I am
entitled to relief The nature of my action, defense, or o er proceedin · .· = ` . =»- .· · · ·
to present on appeal are briefly stated as follows: F I L E D
. — 5 A
U.S. DISTRICT COURT
_ msrmcr OF DELAWARE _
In further support of this application, I answer the following questions.
1. Are you presently employed? Yes El No ·‘
a. If the answer is "yes,"_ state the amoimt of your salary or wages per month, and
give the name and address of your employer. (list both gross and net salary)
lb. If the answer is "no," state the date of last emplo ent and the amount of the
salary and wages per month which you received. Arggd } [ [‘l’l’\ 5
2. Have you received within the past twelve months any money from any of the follow-
ing sources?
a. Business, profession or other form of self—employment Yes El No $*7
b. Rent payments, interest or dividends? I Yes Cl No WZ
c. Pensions, annuities or life insurance payments? Yes El No W
d. Gifts or inheritances? Yes El No Gi
e. Any other sources? Yes Cl No @

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If the answer to any of the above is "yes," describe_ each source of money and state the
amount received from each during the past twelve months. ·,
_ 3. Do you own any cash, or do you have money in checking or savings accounts?
Yes W No El (Include any funds in prison accounts.) {W
If the answer is "yes," state the total value of the items owned.
4. Do you own or have an interest in any real estate, stocks, bonds, notes,
automobiles or other valuable property (excluding ordinary household fumishings
and clothing)?
Yes [I] No G
If the answer is "yes,"_describe the property and state its approximate value .
5. List the persons who are dependent upon you for support, state your relationship to
those persons, and indicate how much yo contribute toward their support.
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I declare under g. of perjury that the foregoing is true and correct. I
if Executed on # - · _
(Date) I `gnature of Applicant
‘ CERTIFICATE
(Prisoner Accounts Only)
I certify that the applicant named herein has the sum of $
on account to his credit at the Sussex Correctional Institution
where he is confined. I further certify that the applicant likewise has the following securities to his
credit according to the records of said institution: l
I further certify that during the last six months the applicant’s average balance was $
(See attached six {6) month statement)
Authorized Officer of Institution
. ORDER OF COURT
The application is hereby granted. Let the
_ applicant proceed without prepayment of
The application is hereby denied cost or fees or the necessity ofgiving
Security therefor.
united states Judge Date United States Judge Date
Or Magistrate