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

‘“ ` — Case 1`E05-cv—00Zi65-Gl\/IS Document 1 Filed 07/05/2005 Pagy; ai y- r rh ; »
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UNITED STATES DISTRICT CO '· is § %
V DISTRICT OF DELAWARE ` ` " `

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S - riatniitr APPLICATION TO PROC O `
Q _ v. WITHOUT PREPAYMENT OF
$ ..S'}»au[e vt fa. ti; [L ,1; f gt`, FEES AND AFFIDAVIT
De endant(s) _
Q CASE NUMBER: O 5 A 6 5
I, e · ‘ J? Ei * * I declare that I am the (check appropriate box)
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° ° l Petitioner/Plaintiff/Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l915, I declare that I am unable to pay the costs of these proceedings and that l am entitled to the relief
sought in the complainupetition/motion.
In support of this application, I answer the following questions under penalty of perjury:
I. Are you currently incarcerated? ° @ ° °No (If "No" go to Question 2) i
l If "YES" state the place of your incarceration 6* ’ iLS /5,; A ·
Inmate Identification Number (Required): .53 (ij; Y
Are you employed at the institution? A gil Do you receive any payment from the institution? A-/C!
Attach g ledger sheet {rom the institution 0[ your incarceration ghgying at least the gas! sb: months'
h·ansacri0ns U
2. Are you currently employed? ° ° Yes
a. If the 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 pay period and the name and address of your last employer.
3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment · · Yes ·
b. Rent payments, interest or dividends • • Yes •
c. Pensions, annuities or life insurance payments • · Yes •
‘ d. Disability or workers compensation payments • • Yes · _
5 I __ e. Gifts or inheritances • · Yes • •
-_ lifter I`. Ally OIIIBI sources • • Ygg • • 1]
in I lf the answer to any ofthe above is "YES" describe each source of money and state the amount
it C received AND what you expect you will continue to receive.

6ase+:05<:v=00¢65—GMS Document 1 Filed 07/05/2005 Page 2 of 2
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4. Do you have any cash or checking or savings accounts? • · Yes @
if "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
· · Ye @
lf "Yes" describe the property and state its value. U
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. H
l declare under penalty of perjury that the above information is true and correct.
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DATE j sto · or AP ICANT
NOTE T0 PRISONER: A Prisoner seeking to proceed without prepayment of fes shall submit an affidavit
stating all assets. In addition, a prisoner must attach a statement certitied 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. _ ,
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