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

- Case 1:05-cv—00285—SLR Document 3 Filed 05/20/2005 Page 1'- of 3
_' · `· _`] * F `- M T an n o ` l, ._ _ L . _ an
-- l ’ nw ‘;- ·if' l I .- sp V- -·, ····· · =» ~· . ·i·—··¢r;~. ·r¤»-Fr; li if-"
w aa. im, in i UNI • · ¤•·. Ul • · to ‘ ·
msriucr 0 • ‘>‘*o`*
x_)ON·A71.[,qAf i/\/CSV
Ptaincin APPLICATION TO PRO
V. - WITHOUT PREPAYNIENTWF
_A _ p _ FEES AND AFF IDAVTT
I fendantfil _. . . . · .—A r-
casn mma ER: _ p _ 3
` L dcdafc that ml ' ` A
H Petitioner/Plaintiff/Ilriovant Cl Other E
in the above—enritied proceeding; that in support of my request to proceed · `t-bout
under 23 USC §1915, Ideclare tlmtl am unable to pay the costs ofthese pro -- · ·; **1 • i·` i" i ..-.
relief sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty ofperjury;
I. Are you currently incarcerated? E Yes G No (If "N0" @0 to Question 2)
` If "YES" state the place ofyour incarceration * · _
Are you employed at the institution? no Do you receive my paymcntlfrom the _
• lf! IJ o l'! H ur 1 -r ·-Lmnagg rr • r fil ' !I fl * * ¤ - 5 Ol 4 g a . ll
in . . . . . ., · i 4 ig ; T; ·-e: ply
Li. gQ{ [gguirgd ggg gfgd guguagf [Q ` -E
2. Are you currently employed? U Yes E No ll
an If the answer is "YES" state the amount ofyour take-home salary or wages and l
give the name and address of your employer. mama Q
b. If the answer is "NO" state the date of your last employment, the amount of
salary or wages and pay period and the name and address of your last employer.
. \Ru 3- In the past 12 twelve months have you received any money from any ofthe following sourcvf l
· - "·i. ·T ' - V
‘ a. Business, profession or other self U Yes J No ¤.
b. Rent payments, interest or dividen` m»-?’€§- _ . ¤ Yes { No ._
C. Pensions, annuities or life insurance pa __· l U Yes p No A fl
d' °' ‘T’°"°°" *““__ . U Y'; » i
l l °' G' °*` mh°“t"“°“ ’·5t*~Z¤ ¤ . * ii‘·- I·‘.i:·s E." .- ” i` --"f A
L Sources ` i' -- if s` .0 ag rréqgo J`. I I
_ _- --·. - _ - · - » » ia-- ~ - -`."i"` y * ”] _
I w évliif -;‘ ¢e·*"“·t»o=‘*·¤~ ai. .- · rn .. " . ,' ·- %•=·»‘ ¤.., , .·,, w- nw _ L I VI A _ ` I ` ea- — i."
U If the aiEver` 6 any or ' ‘‘‘° e‘a o·i·e u ‘*“¤s‘ [ Q Q ; .;é1t'H %uiii‘fe or - ql e
received AND what you expect you will eo receive. J ii.- i l 5;* ," ' S I
· ` et —· ‘ i Y rata;}- § ‘ -” F U -

Case 1:05-cv-00285-SLR Document 3 Filed 05/20/200
4. Do you have any eish or checking or saving: accounts? ¤Ye.s Ao .·
If "Yes" state the total amount S i
5. Do you Own guy ;-ml utnte, stocks, bonds, securities, other I—l¤l¤C·i¤II11S(Fumcnt5, automobiles or other
valuable property?
UY¤ {No
Il' "Yes" describe the property and state its value.
A/awe:
6, List the persons who are dependent on youifor support, state your relationship to each person and I
i indicate how much you contribute to their support, OR state NONE if applicant; ” ‘
{wut? l<1Me€RLY NES * D Foot: l<:·.·.oe wmv WIFEQ
I declare under penalty ofperjury that the above information is true and correct.
.. - ‘ my Qzwt
DATE SIGNATURE OF APPLICANT
k..- r.-- ----·—-
CERTIFICATE
(Inearcerated applicants only)
I certify UIRI Iilc ippuiiut 1]H‘l'1’]Ed I1€I'€iH has thc Sum Ofs { it 'ri Ou I·CCOUI\tI1ISJrI1€l‘ Cftdit Et (HHJTIC
ofinstitutioo) C/Ofugg Qemgg Q Q Q it Mg . _
I further certify that the applicant has the following securities to hisfher credit:
I further eel-tary um during me past stx mouths theiapplicauvs average monthly balance was 5 | [OO. 5 3
and the average monthly deposits were S Q - I 2 . ..
Date SIGNATURE OF AUTHORIZED OFFICER
(NOTE IHF REQUIREMENTINIYEH1 FOR IHEHVJIIAIE TO OBIAINA.NDAZi"L{CHLEDGER SHEETSU
OFACCOUZNT IRABVSACTIONS OVER THEPASTSLXMONIHPERIOD. LEDGER SHEETSARENOT
REQUIRED FOR CASES FILED PURSUANT TO 28: USC 57254) " C ·
- " 1 yi ` " - I °. i

Case1:05-cv—00285—SLR DE>cument3 Filed 05/20/2005 Page30f3
!’ 0}) , A 1 0
¤
# -0 :::2} ‘
M & a ‘0/: s
. ` xxi ’ 3
N s I . ‘
r' \L i
<§>1%_ · -
0% J \é V / -——-
J 0 . ·(" ..»-·
°; 2 A O3 #2
wx .._ jx $1- gg
::5;;
<@ ·¤¤/ Tg
Q I-hi ["“ VE':
J J <¤ wi
M §,p_&· 9 ;§%=i
LJ; RU d ·:··!
0 O xi E
O ~>
1 xr Q
I .42 5
I C!.
\>; W .
Q, j K
5 ° 5 Q E .
YQ E ai g ·
0 g gi zz
i ¤ ¤ é
{ . " M O [3;
1Z* Cd Q ,
2:/ H < ¤ S
vi W 5 E fc
—7" EE q -· ;>—
' E ::1 LG F2 E
Z U) C. ·-< U1