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

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[ Case 1:05-cv—00285—SLR Document 1 Filed 05/10/2005 Page 1 of 4
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‘ ‘ - Case 1:05-cv—OO285—SLR Document 1 Filed 05/10/2005 Page 2`·of 4
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-, M rm, UNITE I `“1 1““1 T
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DISTRICT OF DE ‘ · » · a`·· s ·· s s j· =
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pnsnsrr APPLICATI rr N gg: 4- l
v. - WITHOUT · ·· · — 1 5 —¤;1__ of I
J. `—-by-J. I .` .1 7 »·.. . _ , .· _ .
, FEES AND A AVIT
Defendantls) l O 5 - 2 8 5
CASE NUMBER:
* I, declare that I anx the (check approprwwoz)
lj Petitioner/Plaintii`tTh¤Iova¤t Cl Other
in the Above-entitled proceeding; that in support of my request to pftlcccd Without prepayment of CVJiZLi
under 23 USC §l915, Ideclare tlmtl am tumble tn pay the costs ofthcse proceedings and that I am to tize
relief sought in the complaint/petitionfmotion.
In support ofthis application, I answer the following questions under penalty ofperjury:
I. Are you currently incarcerated? U Yes Cl No (If"No" go to Question 2)
` lf "YES" state the place of your incarceration $,,,»,“.,c,,_, ,,,,,,
Are you employed at the institution? Do eceive my piymentifrom the instituti
• IH U l f! lf NY 1 ea : e- ran g! = _r_[{’!I 1.1 Ol • ¤ e d 4 1 -•
{LL ` . r v • » . ` e e u u 1 11.1 .. · 41;;;, I
2. Are you currently employed? El Yes Cl No
L If the answer is "YES" state the amount of your take-home salary or wage; and p : =
give the name and address of your employer. I "
l b. If the answer is "NO" state the date of your last employment, the amount of your
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 of the following sources?
‘ a. Business, profession or otlier self-employment C1 Yes ¤ No
b. Rent payments, interest or dividends _ . U Yes U No
c. Pensions, annuities or life insurance payments l ¤ Yes C1 No
Ci- Disability or workers conmugjqu paymmu ¤ yes l U J l . ·
<=· Gifts or inheritanees F, ¤ Y ;
7- = .‘o~ r - ·<¤=f;#%E; _ . I
L ‘°“‘I °“"°' ‘°‘"°?s , , s o I
lfthe answer to any on t - e Y IS t n A our ei nsoogyn lh Qi nt r
received AND what you expect you will eontinue to receive. ` at I

Case 1 :05-cv—OO285—SLR Document 1 Filed 05/10/2005 Page 3 of 4 · ’ _ ·
4- Du YOU IIIVQ [ny CiSll ur ch ,;.; Z,§;w. _y i! ¤Y¢$ Q N0 • i
If"Yes" state the total amount S
5. Do you own any real estafc, Sl0Cl valuable property? p
¤Yes Q No ·
If "Yes" describe the property and state its value. i
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6. List the persons who are dependent on youifor support., state your relationship to each person and }
` indicate how much you contribute to their support, OR state NOAE if applicabli; ` i
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I declare under penalty ofperjury that the ahove information is true and correct.
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DATE SIGNATURE OF APPLICANT
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CERTIFICATE
(Tncarcerated applicants only) -
I Crmiify that the applicant named herein has the sum ot'S ` on account hjsjhcr credit at (name
of institution) _
I further certify that the applicant has the following securities to his/her credit:
I further certify that during the past six months thciapplicanfs average monthly balance was S i
and the average monthly deposits were S , ,p

Date SI OF AUTHORIZEJZ3 DFFICER
UVOTE YHFREQMREMEWINITEH1 r I '.._ HLEDGE `
:i me- ·` ··’; ·e»¤¤~l;-;·l·4».a‘.--e *t¤ ‘ :55: .... R SHEET}?
OFACCOUTVT IRANSACTIONS OPER -l TSIXMONTH _ _ ETSARE NOT
MQUIRED Fox cases may PURSUANT ro zsivscpzsa; s `‘·` , .
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_ Case 1:05-cv—00285—SLR Document 1 Filed 05/10/2005 Page 4 of 4
U I DELAWARE CORRECTIONAL CENTER
INHATE REQUEST FOR CERTIFIED TRUST FUND
ACCOUNT STATEMENT OF PRIOR SIX NORTH PERIOD
TD: Hr. Joseph Hudson, Manager DATE:
Delaware Correctional Center
Smyrna, Delaware 19977
ERON:
Inmate Name (Please print Name) 65I#
- I HEREBY CERTIFY —
Pursuant to the Prison Litigation Reform Act, 28 U.S.C. 1915
(a)<2), effective April 26, 1996, I am 'requesting a certified
Statement of my Institution Trust Fund Account for the previous
six month period. Please forward same to me.
Signature
(Q6 U.S.C. 1746 and 16 U.S.C. 1621)
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