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

Case 1:05-cv—00295—SLR Document 1 Filed 05/13/2005 Page 1 of 2
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
riaaaarr APPLICATION TO PROCEED
·- N v. WITHOUT PREPAYMENT OF
fi g ' ~ "~‘ 4 FEES AND AF FIDAVIT
ndant(s) _ I ``'' J i
CASE NUMBER: g aw 5
I. Y P _ ._ _ . declare that I am the (check appropriate box)
III Petitioner/PlaintiI`f`/Movant El Other
in the abeve—entitIed proceeding; that in support of my request to proceed without prepayment of Fees or Costs under
28 USC §l9 I 5, I declare that I am unable to pay the costs ofthese 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:
I. Are you currently incarcerated'? EI Yes me (If "No" go to Question 2)
lf"'YES" state the place ofyour incarceration _ _ _ it ._ _ _. _,.w;ag.-§.§.g ag
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution'?
Attach u ledger sheet {rom the institution 0[ your incarceration showing at least the past six niont/:s’
tmnmciiorrs
2. Are you currently employed? D Yes Mo
a. lfthe 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 ofyour last employment, the amount of your takc—g)>me _
_salar or t rages and pay period and the t . ~~ you last employer. / 5; 9
/ .r<.» &·¢’7" _ $; ’ dl ,
3. In the past I2 twelve months have you received any money from any ofthe follo g SO IFCBS?
a. Business, profession or other self-employment D Yes U/No
b. Rent payments, interest or dividends D Yes D/No
c. Pensions, annuities or life insurance payments D Yes o
d. Disability or workers compensation payments D/Yes I I o
e. Gilis or inheritances D Yes D/No
f. Any other sources D Yes D No
lf the answer to any ofthe 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—00295—SLR Document 1 Filed 05/13/2005 Page 2 of 2
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al. Do you have any cash or checking or savings accounts? V Yes @ @0
lf "Yes" state the total amount fi?
5. Do you own any real estate, stocks, bonds, securities, other financial instruments. automobiles or other
valuable property?
KV/Yes U 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 ifapplicable.
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l declare under penalty of perjury that tlte above information is true and correct.
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ATE KFIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeldng 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.