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

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» pm, om UNITED STATES DISTRICT CO F i 1 in ~ gi
DISTRICT OF DELAWARE i Q £ .
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Plaintiff APPLICATION TO . .
V. ~ WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
Defendantggl I ii '“i""r-~· " U -
,/"Y» S ; _ casa woman; 0 5 — 2 at 2
' I, Z/ declare that I Hm the (check appropriate box)
ij/I Petitici§fPIaintiff!Mova¤t Cl Other I
in the abovc—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC §1915, 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/pctitionfmotion. '
I
In support of this appliiation, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? dhs G No (If "N0" go to Question 2)
‘ If "`Y”ES" state the place of your incarceration 6 I s . . Y
Are you employed at the inst:ituti0n?: Do you receive my paymcntfrom the institution? __
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I .1* u r l. I t em u :u.4 ;·¢: ¢.!n H. $::.*11 Iea yo u I ‘ *=¢ ‘%’ `
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2. Are you currently employed? D Yes mic T'
a. If the answer is "YES" state the amount of your take—home salary or wages and paylpcriod 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 tal 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? 1
‘ a. Business, profession or other self-employment D Yes j3/ No __
b. Rent payments, interest or dividends _ . ¤ Yes O/ No
c. Pensions, annuities or life insurance payments ` D Yes No
d. Disability or workers compensation payments C1 Yes 12( No
e. Gifts or inheritances U Yes El! No y
f. Any other sources U Yes g/ Nu _
If the answer to any of the above is "Y`ES" describe each source of money and state the amount
received AND what you expect you will continue to receive. 3)

00282-GMS Document 1 Filed 05/10/2005 Page 2 of 2
4. Do you have any cash or checking or savings accounts? ¤Yes JN0 -'
If "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? {
¤Yes No
If "Yes" describe the property and state its value
6. List the persons who are dependent on youfor support, state your relationship to each person and
f ` indicate how much you contribute to their support, OR state NONE if applieablgy A '
g I declare under penalty of perjury that the above information is true and correct.
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DATE, SIGNATURE OF APPLICANT
l
i CERTIFICATE l
I (Incarcerated applicants only)
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l I certify that the applicant named herein has the sum of S l ou account his/her credit at (name
i ¤r institution) .
I further certify that the applicant has the following securities to his/her credit:
J .
. I further certify that during the past six months the applicant's average monthly balance was S I
V and the average monthly deposits were S . ;
{ _,_.___________
I Date SIGNATURE OF AUTHORIZED OFFICER
(NOTE IHEREQUIREMENTINIYEM1 FOR THEINMHE T0 OBTAINANDAIT`ACHLEDGER SHEETS
{ OFACCOUNT IRAMSACYYONS OVER UJEPASTSLXMONIHPERIOD. LEDGER SHEETSARE NOT
_ REQUIRED FOR CASES FILED PURSUANT TO 28:USC §2254) -.

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