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

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89 Fil? 08/24/2005 Page 2 ¤r 3
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l l A0 24Q§§£_§·égE-cv-00583-JQH Document 89 Filed 08/24/?OO5 Page 3 of 3
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A · Plamf · A APPLICATION TO D l2= 53 F
»— WITHOUT PREPAYL\@ENT.0F.. l
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LME5 \_@`°N`%€; FEES AND AFFHJAVITL _‘ ;;—g`:g§,‘i?,‘.;, S; ·%}l§»ji‘ll ¤
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Defendant J case Numeen; 310 S C Us Y 3(TC H) l
I, LUBS déél>___(;E~ ’ declarethatlarnlltefcheclc epproprlatebou J
E petltionerfplalntitllmovant Q other i
' ln the above—entltlecl proceeding; that ln support otmy request to proceed without prepayment ottees orcose
underze USC. 51915 I declare that I am unable to pay the costs ofthese proceedings and that l em emitter
to the rellet sought in the cornplalntlpetltlon/motion. i
In support of this application. I answer the following questions under penalty ct perjury: A
1. Are you currently incarcerated? EQ I] No (lf "No' go to Partz} _ l
If "Yes' state the place ot your lncarceratlon
Are youpéplplgygg at the institution? °"//_Do you receive any payment from the lnstltutlcn?~§ € Lg
mort aélledggg (sheet from the lnstltutlon(s) of your incarceration showing at least the past slx months
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·’ "· p`·‘!‘*·¤$rr¤··@ri;`_€lmol¤y¤d2 A _ . El No . _. . y
r . ·° U te>`°·=Er·tsw§§‘Yes'statetl1e amount ctyourtake-home salary orwegesoncl endg the l
gl ei Q tt ofyouremp|¤yeh)jg g -&$`_o_»eelLt¤‘ oat y
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E te answer ls 'No" state the date otyourlast employment. the amount ot your teke·—heme salary o E
.g gee and pay period and the name and address ol your last employer. ‘
2 \ vesttzmelyemonmshaveyourmodveqmymoneyeomenyotthelolowlnosowcss? l
L: E slness. profession or other selt—ernployment I;] Yes E/N0
¤ E nt payments. Interest or dividends - _ lj Yes Q’Nc . -
E N ·; nslons. annuities or life insurance payments []. Yes ‘ Elle ‘
EI E sablllty or workers compensation payments I] Yes ?o l
5 _ ltsorlnherltances I]Yes No.-
: 2 y other sources ' I] Yes E}’Ne
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*5 § tswerto any ofthe above ls 'Yes" describe each source of money and state the amount received ent i
E ou expect you will continue to receive. i