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


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Pages: 2
Date: August 16, 2005
File Format: PDF
State: Delaware
Category: District Court of Delaware
Author: unknown
Word Count: 610 Words, 3,968 Characters
Page Size: Letter (8 1/2" x 11")
URL

https://www.findforms.com/pdf_files/ded/8293/63.pdf

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; _ _.- ., , L, .. . _., ,,,_ ___ —=»-‘•= ~·->*--•¤t·-- ii%—•·->·—•..- ,- .
s.. UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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p Plaintiff _, APPLICATION TO PROCEED
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—¤'s`~ at - ¤- ta- - F" ‘ . S3£?’l`*fa?l“§ . .
l LT r . »»— - FEES AND AFFIDAVIT
t Defendant(s)
p CASE NUMBER: QA,- Q
L ° 7 _ _. C` declare that I am the (check appropriate box)
• • r i Q ; - - U I • |
Petr 10 er/Platnttf£[Mdiant Other
{ in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
1 28 USC §l915, I declare that Iam unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
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In support of this application, I answer the follouiyg questions under penalty of perjury:
l. Are you currently incarcerated? ° es _ _ ° ____ _

lf "YES" state the place of your incarceration l [email protected][ " ·?l*"°f"M”;`*` ·° [email protected]
Inmate Identification Number (Required): _ » _ ' _ r' '
Are you employed at the institution? Do you receive any payment from the institution? “ "
Attach a ledger sheet [rom the institution of your irrcczmemtiozz showing at feast the gas! six? mouths `
!rcmsrrcti0n.s _
2. Are you currently employed? ° °Yes ° NJ ` I
a. Ifthe answer is "YES" state the amount ofyour take—home salary or wages and pay period a i
and give the name and address of your employer.
b. If the answer is "NO" state the date of your last employment, the amount ofyour take-home
salary or wages and pay period and the name and address ofyour last employer. - __ ,_ \
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3. In the past I2 twelve months have you received any money from any ofthe following sources? IO)
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a. Business, profession or other self-employment · · Yes • • N4
b. Rent payments, interest or dividends · · Yes °· · N "
c. Pensions, annuities or life insurance payments · • Yes · - i r .
d. Disability or workers compensation payments · • Yes v .-.——·—·~ i t- -. M ·‘r‘ M
e. Gifts ormherttances • · Yes . A · ·- • i i.
f. Any other sources . . Yes .. ' p o — ·s·» ,
Ifthe answer to any ofthe above is "YES" describe each source ofmoney and state the unto .
received AND what you expect you will continue to receive. = p
.. . ... _

. _,‘· .SLR Document 63 Filed 08/10/2005 Page 2 of 2
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l` AO2-$0 Re»er·sc(Rev. lL‘,fU3)
L, DELAWARE sRev, 4f051
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4. D0 you have any cash or checking or savings accounts? • · Yes • (NO)
E
ll It` "Yes" state the total amount S
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` 5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? (NO) .
· · Yes ·*jNo
lf "Yes" describe the propeny 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. NON;
[declare under penalty of perjury that the abo qc i formation is true and correct.
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DATE ‘ 1·i.1cAN‘t, F .
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NOTE TO PRISONER: A Prisoner seeking to proceed 1 t e . repayment of fees shall submit an affidavit
stating all assets. In addition, a prisoner must attach a statement certilied by the appropriate institutional
oflicer 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.