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

. Case 1 :04-cv-01239-SLR Document 20 Filed 11/07/2005 Page 1 of 4
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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T-\_\ CI _ Plaintiff yII.._\I,L Qp`I,I&,I APPLICATION TO PROCEED
I Q WWAS lniik ;y\\V_ III _I_I_Ov NMI I WITHOUT PREPAYMENT OF ,3>;I_gQ2_
Mu asa g tg Q Q I I I,‘ , Ig I FEES AND AFFIDAVIT obi"?
Defendant(s) .
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° ° Petitioner/Plaintiff/Movant ° °' Other
in the above—entitled proceeding; that in support of my request to proceed without preq;a#eiit—of fees oiivciopts Iggdetri "" "`I
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and hat lIa.rrLQfiI.i1I€2£ii@ii2.€LIlief I
sought in the complaint/petition/motion. I I
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In support of this application, I answer the following questions under penalty of petjuiy: I
1. Are you amenity iaemmiaa·2 ° °N¤ (tr·*N¤·· ge I
If"YES" state the place ofyour incarceration · Q ·I Q :
Inmate Identiiication Number (Required): iii
Are you employed at the institution? IYy*I`ig Do you receive any payment from the institution?
Attach cz ledger sheer from the z`nstfn·t!i0:z of vottr fncarcemtion sfmwirzg at least I/ze Uris.! sir mont/is"'
IVGPISJCHOJTS _,..3_\
2. Are you currently employed? ° ° Yes ° QQ
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a
and give the name and address of your employer.
b. if the answer is "NO" state the date ofyour last employment, the amount of your take—home_
salary or wages and pay period and the name and address ofyour last employer.
3. in the past I2 twelve months have you received any money from any of the following sources? I
a. Business, profession or other self-employment · · Yes
b. Rent payments, interest or dividends * * Yes • • I i
c. Pensions, annuities or life insurance payments * ' Yes Cf ‘i I
d. Disability or workers compensation payments · · Yes ` · •
e. Gifts or inheritances · · Yes
f. Any other sources · · ’Y·e's‘\ · · No
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It` the answer to any ofthe above is "YES" describe each source ofrnoney and state the amount
received AND what you expect you will continue to receive. I I

_ Case 1:04-cv-01239-SLR Document 20 Filed 11/07/2005 Page 2 of 4
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4. Do you have any cash or checking or savings accounts? - · Yes · 1No t
lt"'Yes" state the total amount S U
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
valuable property? "`\
• • Yes · •NU
lt` "Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state r relationship to each person and
indicate how much you contribute to their support, OR $[3l4’£\’-ONEf1f applicable. _
I declare under penalty of perjury that the above infomation is true and correct.
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DATE SIGNATURE OF APPLICANT ~
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an aflidavit
stating all assets. In addition, a prisoner must attach a statement certiiied by the appropriate institutional
ofticer 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.

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