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

Q Case 1:04-cv-00870-JJF Document 30 Filed O3/06/2006 Pagei of 4

Qgutteh §tzt1:ez ggtrairtci Glumct
DISTRICT OF
@3 (H ( ,aO,,,_i·;c»€, APPLICATION TO PROCEED IN
LJ -/‘ ‘ FORMA PAUPERIS, SUPPORTING
v_ . DOCUMENTATION AND ORDER
//;O,rn@ic‘5 C/474 rfrjill C-/é O,_[I_ CASE NUMBER: O Q; ' U
’ # D£4¢O“/-—‘ii’70 TJ-?
, declare that I am the {check appropriate box)
IZ/petitioner/plaintiff Q movant (filing 28 U.S.C. 2255 motion)
Q respondent/defendant Q
other
in the above—entitled proceeding; that, in support of my request to proceed without being
required to prepay fees, cost or give security therefor, I state that because of my poverty, I
am unable to pay the costs of said proceeding or give security therefor; that I ' v I am ___________
entitled to relief. The nature of my action, defense, or other proceeding or the iss [KZ C -
` to present on appeal are briefly stated as follows: '...i *2. ._s,,__,_,. ,
g W;}-I T - Li` nf- l
us. 0i§¥r$i`E:r courir
—- DISTRICT OF DELAWARE ’ _j
In further support of this application, I answer the following questions. I - 4/PC!
I. Are you presently employed? Yes Q No {
a. If the answer is "yes," state the amount of your salary or wages per month, and , ·
give the name and address of your employer. (list both gross and net salary) A/f/H \
b. If the answer is "no," state the date of last employment and the amount of the ‘
salary and wages per month which you received.
2. Have you received within the past twelve months any money from any of the follow-
ing sources? /·’
a. Business, profession or other form of self·employment {Yes Q Noi]! __
b. Rent payments, interest or dividends? Yes Q No
c. Pensions, annuities or life insurance payments? Yes Q No E
" d. Gifts or inheritances? Yes [22]/ No Q /,
.,,~ ·~ e. Any other sources? Yes Q No 1Z/

_Oase 1:04-cv-00870-JJF Document 30 Filed O3/06/2006 Page 2 of 4

If the answer to any of the above is "yes," describe each source of money and state the _ A
amount received from each during the past twelve monthsfzfgm T]?
3. Do you own any__cas , or do you have money in checking or savings accounts? .
Yes Q No (Include any funds in prison accounts.)
‘ lf the answer is "yes," state the total value of the items owned.
V 4. Do‘ you own· or have any interest in any real estate, stocks, bonds, notes,
automobiles or other valuable property (excluding ordinary household furnishings
and clothing)?
Yes Q No @/
- If the answer is "yes," describe the property and state its approximate value.
5. .List the persons who are dependent upon you for support, state your relationship to
those persons, and indicate how much you contribute toward their support.
l declare under penalty of perjury that the foregoing is true and correct.
O Executed on ‘
(Date) Signature of Applicant
CERTIFICATE
(Prisoner Accounts Only) Q ·
I certify that the applicant named herein has th sum of $ l Za ‘ s
on account to his credit at the Q · _ _
institution where he is confined. I further certify that the applicant likewise has the following securities to
I further certify that during the last six months the appli ant’s aver
Ptut zed Officer of lnstitution
· - _- ` ` ORDER OF COURT
The application is hereby granted. Let the
applicant proceed without prepayment of
The application is hereby denied cost or fees or the necessity of giving secur-
Q ity therefor. _
( United States Judge Date .United States ludge Date
te? _ or Magistrate
Q . ..1
4%; .r P 1 "

Case 1 :04-cv-00870-JJF Document 30 Filed O3/06/2006 Page 3 of 4
Certiticate of Service
I `
I, ;€B(`,.; [ lf ) [IO I I}-iggg , hereby certify that I have served a true
and correct cop(ies) ofthe attached. { . · QC-7 ; _ ar`·(—° .»_. .·
~\_T_/ ·"* it i· A J
ly Y/g') {`· tt;} {il lg Og I · lg.? 1"'QC upon the following
parties/person (s):
TO: ptr-,jlp75`·¤,C,{ (\(§t_.l,l¤£ (wl -e- pf-) TO: _ ‘·{+. IU , Q `~ -· ‘· -! ,
§` tl . C,. ll") -·-;t';y·t r--{ Qt-; wt. Q);--F {5 T if "IL ‘CQ,’i’_.
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|"\n_ I `·" ,—}_’/
ll ; §‘g‘g“»- St . V".! I-Il pf J; l iv. . - Z0; Q Q; tj
TO: TO:
BY PLACING SAME IN A SEALED ENVELOPE and depositing same inthe United
States Mail at the Delaware Correctional Center, I l8l Paddock Road, Smyma, DE
19977.
_ ,,...j¤.=· `J {
On this cy, 6 day of {fj J · 1 KY'} ' 'f* , 2006 A,
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Case1:O4—cv-00870-JJF Document 30 Filed O3/06/2006 Page40f4
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