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

Case 1 :05-cv-00345-SLR Document 20 Filed 05/21/2007 Page 1 of 4
0 AO 24 (Rev. IO/O3)
O DELA\\AR.E(Rev. 4/OS
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
v. WITHOUT PREPAYMENT OF
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I, _ lvl { S iq g ”,;\ {tj {I, Lf- ii-- ___ declare thatI am the (check appropriate box)
El Petitioner/Plaintiff/Movant Cl Other
in the above—entitled proceeding; that in support ofmy request to proceed without prepayment of fees or costs under
28 USC §l9l 5, 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, I answer the following questions under penalty of perjury: . ‘
1. Are you currently incarcerated? El Yes ` No (lf "No" go to Question 2) __
If "YES" state the place of your incarceration _ ` . , . L _ _
Inmate Identitication Number (Required): "M - _ __Ii
Are you employed at the institution? Lx .1 Do you receive any payment from the institution? LLJQ
Attach a ledger sheet from the institution of your incarceration showing at least the gas! six months '
transactions
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2. Are you currently employed? ml Yes Cl No
c =" Ti? ir; , ~ i 5 I lyigrigqjwtj Vet?. Fw.- a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a U
and give the name and address of your employer. ,-1 if ; N.] in‘.·,.?l Ll ug C. Lt‘tOf)•£J?— C U
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b. If thélanswer 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 I2 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment E1 Yes IQ I No
b. Rent payments, interest or dividends C1 Yes B] No
c. Pensions, annuities or life insurance payments E1 Yes EV No
d. Disability or workers compensation payments E1 Yes l.§t/No
e. Gifts or inheritances D Yes Kg/No
f. Any other sources El Yes El ”'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-00345-SLR Document 20 Filed 05/21/2007 Page 2 of 4
U S COURT OF APPEALS, THIRD CIRCUIT
Summary Of Current Assets:
Checking accounts A $ 20,500
Summary Of Current Liabilities:
Credit Card Debit S5 26,000
Promissory Notes 6,500
Medical Bills 300
Legal Bills 6,800
Total $ 39,600

Case 1:05-cv-00345-SLR Document 20 Filed 05/21/2007 Page 3 of 4
AO 240 Reverse (Rev 10/O3)
DELAWARE Rev. 4/05
4. Do you have any cash or checking or savings accounts? Q Yes D No
lf"Yes" state the total amount $ dit Fit I ’
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? [
T lll [`*·i" tr.-`i\_,' .rr‘··.‘-L 2. ·`·i¤`·<~t c‘.~- T j g< at YES E NO
If "Yes" describe the property and state its value.
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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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DATE 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 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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