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

__ Case 1:05-cv—OO187—SLFl Document 1 Filed O3/28/2005 Page 1 of 2
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LNIT ED STA'] ES DIS YRICT COUR1 § " *if I
DISTRICT OF DELAYVARE
Plzunttfl r\I’PLICr\TIO?\ TO PROCE ·. _r — ‘
` ' " " WITI-[OUT PRIiP.—\YMEl V1 FEES AND AFFIDAVIT
Dcfentlantls) T { in k .._ _ CASE NUMBER: U tm 1 {3 T
I, ~ I/II declare that I ani tit: · box)
`Petitioner/Plaintiftlhlovant Other in the abovc—entitled proceeding; that in supp@§ of my
request to proceed without prepayment of fees or costs under 28 USC §l9l5, I that I am
unalile to pay the costs ofthesc proceedings and that I am entitled to the reliefsougltt in the
CODIPIHIIIIJIDCIIIIOIIIIITIOIIOTI.
In support oftltis application, I answer the following questions under penalty of perjury:
I1 Arc you currently incarcerated? I] No (If"No" go to Question 2)
If "YES" state the place of your incarceration l "' C I if ‘ i -0
Are you employed at the institution? lQ’Yes I] No
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Do you receive any payment from the institution? E’Yes [I No
Have the in.s‘!i!m‘!m·r if} out ` &'MJ.t'[f zcrue oriion 0 thi.? rt mlcrvit mrc} crime}: ct /·2d¤t?t‘
iiisrizirtim-i 1v 0 `vorn- incrircei-orion1·:!iowiizv at least the ost .S'!X»ionrhs' rr·r.·n1rricri‘on1i·.
xfzeets are not rerurirec! or crmzs z}ed0ztn·.si1n·n! to 28: USC §225~!1 ;
2. Are you currently employed? [1 Yes
a. [fthe answer is "YES" state the amount of your take-home salary or wages and pay period and
give the name and address ofyour employer.
b. Ifthe answer 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. / Qs
3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. profession or other seltiemployment Yes No
b1 Rent payments, interest or dividends Yes
c. ` Pensions, annuities or life insurance payments i Yes
cl. Disability or workers compensation payments Yes _
e. Gifts or inheritances Yes
f1 Any other sources E3 Yes @/7%
If 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.

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It`"Yes" state the total ainonnt b /··”' - -
5, Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or
other valuable property? El Yes [E/No
It"‘Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state your relationship to each and
indicate how much you contribute to their support, OR state .VO.-VE ifapplicabie.
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I declare under penalty ofperjury that the above information is . . ii-. correct. __
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