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

. Case 1 TO4-cv-01561-KA;} ‘ Doctfment 17 Filed 07/20/2006 Page 1 of 2
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
h P Piaimirr is APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
5,/yl MQIQ] §b®ag .jj£{QI I FEES AND AFFIDAVIT
Defendant(s) - _ _
case NUMBER: (liv, A .t\lt>» ·'>*·l·‘l5*'¤l `WJ
I, Igffg IQ I img fi _ declare that I am the (check appropriate box)
Y laintit`f7l\/Iovant ° ° Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and a l·····l ·- »t.- : I..e.. sought in the complaint/petition,/motion. I I I § § §_ E S ?
In Support of this application, I answer the following questions under penalty ofpetjuty 2 U
l. Are you currently incarcerated? °><*r'es ° °No (If "No" go to 6Sti I ...... . iii. ,. M, ,___ ___ I
, I}l$`I`FtiCT CDU in
— ` _ . I 3 t -
If "YES" state the place of your incarceration !_ ;_ I .,: - j - ‘ ` c q, I
Inmate Identification Number (Required): 2,59.. if
Are you employed at the institution? Do you receive any payment from the institution? gis
Attach o ledger sheet from the institittion of vour incarceration showing at least the mast six: mont/zs"
trarisactfons
2. Are you currently employed? ° ° Yes ° No
a. If the answer is "YES" state the amount of your tal 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 take-home
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? -.
I a. Business, profession or other seltlemployment - · Yes 'H No
b. Rent payments, interest or dividends • • Yes •>< No
c. Pensions, annuities or life insurance payments · · Yes EP" No
d. Disability or workers compensation payments · · Yes :7* No
e. Gifts or inheritances · · Yes •‘;•=No
I f. Any other sources · · Yes 7*No
lf the answer to any of the above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.

Case 1 :04-cv—01561-KAJ Document 17 Filed 07/20/2006 Page 2 of 2
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4. Do you have any cash or checking or savings accounts? • • Yes •$(No
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? A
• • Yes ·>(No
If` "Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how much you contribute to their support, OR state NONE if applicable. p
Non L
I declare under penalty of perjury that the above infomation is true and correct.
{__ ‘••-. _____.;7
DATE SIGNATURE OF APPLICABIT —
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
officer showing all receipts, expenditures, and balances during the lastsix months in your institutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.