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

Case 1 :04-cv-01417-GIVIS Document 10 Filed 01/10/2006 Page 1 of 4
AO240 (Rev. 10/03) ·
" DELAWAREtRev. 4{OS)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
·Nx\x\CL Q, L .
Piaimirr APPLICATION TO PROCEED
) . V. _ - WITHOUT PREPAYMENT OF
"·t —~.<§xs 'C-.»e.·<< `I.&1x{\`{`\L>x. \Q¤L.x;\ ·;.t..x.. FEES AND AFFIDAVIT
Defendant(s) _
ci-xse NUMBER; oel · l‘~l l 7
I, \'\ S‘\ DAX t declare that I am the (check appropriate box)
Petitioner/Plaintiff/Movant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed A itho osts nder
28 USC §l9I5, I declare that I am unable to pay the costs ofthese proc edin and that I am entitleB1$@E Eq5_D C
sought in the complaint/petition/motion. 1 U I ‘
PEC 0 2005
In support of this application, I answer the following questions under pen ity of p€l1!jSrY>tSTFslCT Ctwg
( _. .. _ LR UERICT OF DEL/M . EORTS WCES
l. Are you currently incarcerated? ° Yes ij ° °No (If "No" go to Ouestion Zi MANAGER
If "YES" state the place of your incarceration {Q-me ( e.t.Es.. t Q- t¤>.rt\n‘€ .
Inmate Identification Number (Required): //1
Are you employed at the institution? A A Do you receive any payment from the institution?
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast six m0nths'
transactions
2. Are you currently employed? ° ° Yes FE5 ‘ l
a. Ifthe answer is "YES" state the amount ofyour take—home salary or wages and pay period a
and give the name and address of your employer.
b. Ifthe answer is "NO" state the date ofyour last employment, the amount ofyour tal salary or wages and pay period and the name and address of your last employer.
3. In the past I2 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment · • Yes itz .·`No`
b. Rent payments, interest or dividends • • Yes o B
c. Pensions, annuities or life insurance payments · • Yes No I )
d. Disability or workers compensation payments • · Yes i ‘e• .•"]$lo"")
e. Gifts or inheritances · • Yes om
f. Any other sources • · Yes ‘ • · No
lfthe 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.

Case 1 :04-cv-01417-GIVIS Document 10 Filed 01/10/2006 Page 2 of 4
AO 240 Reverse (Rev. 10/03)
DELAWARE {Rev. 4{D5
. . ./’
4. Do you have any cash or checking or savings accounts? • • Yes g•__;No
If "Yes" state the total amount $ /L/ [ Q
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? -—-~e .
If "Yes" describe the property and state its value.
i
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.
/l A Ak
I declare under penalty of perjury that the above information is true and correct.
”~·’*‘/»—*·¢’§ if/¤ ger r~ l K- e
DATE _ SIGNATURE OF APPLICANT
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
ofiicer showing all receipts, expenditures, and balances during the last six 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.
— 5

Case 1 :04-cv-01417-GIVIS Document 10 Filed 01/10/2006 Page 3 of 4
CERTIFICATE
(incarcerated applicants only)
(T0 be completed by the institution ot incarceration)
I certify that the applicant named herein has the sum of S QT on account his/her credi t (name
ofinstitution) lj! A Q ; L { /22
I further certify that the applicant has the following securities to his/her credit: R (_] 3 g
I further certify that during the past six months the applicant‘s average monthly balance was $ *
and the average monthly deposits were $ ( l l
Date Signature of Autfiiied Officer
(NOTE THE REQUIREMENTIN ITEM] FOR THE INMATE TO OBTAINAND ATTA CH LEDGER
SHEETS OFACCOUNT TRANSACTIONS OVER THE PAST SIXMONTH PERIOD. LEDGER SHEETS
ARE NOT REQUIRED FOR CASES FILED PURSUANT TO 28: USC §2254)
RECEIVED-D.C.C
DEU 2 R ZUU5
SUPPORISEFH/lCES MANAGER

Case1:04-cv—01417-GIVIS D0cument10 Filed 01/10/2006 Page40f4
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