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

Case 1 :04-cv-01232-GIVIS Document 17 Filed 12/23/2005 Page 1 of 2
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DEL.\WARE(llev 4/05) .
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Piamirr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
-;;gQmg© Q Elggg , ;,-Egmgjj FEES AND AF FIDAVIT
, Defendant(s)
CASE NUMBER: OL} - LQBQ ,ém5
I, Eégpyi I1] K [ Iglhj gu--gl:] declare that I am the (check appropriate box)
"6 Petitioner/Plaintiff/Movant ° ° Other
in the above—entitled proceeding; that in support of my request to proceed without prepayrnent of fees or cdsts tirrdc-tig www
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relie-fee-»
sought in the complaint/petition/motion. I I q
g . i"]?32005 I
In support of this application, I answer the following questions under penalty of peijuryzi . _ _ _ L
I ‘l "2Y""‘iI e
I. Are you currently incarcerated? °°/Yes ° °No (If "No" go to Qpegggnl) ’ "` _ "‘Eq_________H
If "YES" state the place of your incarceration gp, Emglgg; C Dgggglzmgm QE-! EE E
nel @ic·:;x;mz =12c>»=—»i;> zsmvizua . br; wmv
Inmate Identification Number (Required):
Are you employed at the institution? gg.; Do you receive any payment from the institution? ygél
Attach a ledger sheet from the institution of your incarceration showing at [east the gast sb: mont/1s'
transactions
2. Are you currently employed? °`/° Yes ° No i
a. If the answer is "YES" state the amount of your talge—home salary or wages and pay period a
and give the name and address of your employerdbébvg m;5;5jr§~ti.Y. '·9?`{Z1Lrj3i>
we ·<1 - D8: 9-’1w.¤·:>;>c:r;}·‘: >1?c>»=->¢:» z'>m~!2¤>t=~# ,‘a‘;·& JQGOO -
b. Ifthe answer is "NO" state the date of your last employment, the amount of your tal 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? .
a. Business, profession or other self—employment · • Yes ·“/No
b. Rent payments, interest or dividends • · Yes No
c. Pensions, annuities or life insurance payments · · Yes M No
d. Disability or workers compensation payments · • Yes ·'·*" No
e. Gifts or inheritances · • Yes ·|/No
f Any other sources • · Yes •*{No
If 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—01232-Gl\/IS Document 17 Filed 12/23/2005 Page 2 of 2
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DEL,·\W.-\RElRev 4/05l
4. D0 you have any cash or checking or savings accounts? • • Yes ·•/ No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
• · Yes J No
lf "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. MORSE-
l declare under penalty of perjury that the above information is true and correct.
Q A j, t
_, L-- __,. 1&!.·£?
DATE NA • ·• or 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
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.