Free Letter - District Court of Delaware - Delaware

Case 1:04-cv-OO241—Gl\/IS Document 22-2 Filed 12/O1/2005 Page 1 of 2
AO 240 iFl¤v. 6!86l Application to Proceed 9
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DISTRICT OF _ I MANAGER
C£>P2€¤£»<:>2y pg Mgycm APPLICATION TO PROCEED [N
., = J FORMA PAUPERIS, SUPPORTING
v_ , DOCUMENTATION AND ORDER
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L ` - I · declare that l am the (checkappropriate box)
[glpetitioner/plaintiff lffmovant (tiling 28 U.S.C. 2255 motion)
Q respondentjdefendant 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 therefdr, I state that because·ot_mypogeny, i _ -te=·- ~ -
am unable to pay the costs of said proceeding or give security therefor; that I lielieye 1 3 5 ° -~
_ entitled to relief. The nature of my action, defense, or other proceeding • intern § . 5
to present on appeal are briefly stated as follows: > —· ` 5 ‘ ~ l
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in further support of this application, I answer the following questions. I db `
1. Are you presently employed? _ .A I Yes |j/ No
a. if the answer is "yes," state the amount of your salary or wages per month, and
give the name and address of :_ r employer. (list both gross and net salary)
. =*i*>>>’ $B<> `?·°’·
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ci>i—rne.~e—ie rorerae; -
b. If the answer is "no," sta " ’“ date of last employment and the amount of the t
salary and wages per month which you received. I
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 sell-employment (Yes Q N0_Q/
b. Rent payments, interest or dividends? _ Yes Q No [gf
c. Pensions, annuities or life insurance payments? Yes Q No Q'
“ d. Gifts or inheritances? _ Yes ij No [Q"
we ~ e. Any other sources? _ Yes Q No ij?

‘ " Case 1:04-cv-OO241eGil\/IS Document 22-2 Filed 12/O1/2005 Page 2 of 2

lf the answer to any of the above is "yes," describe each source of money and state the
amount received from each during the past twelve months. e ‘b‘‘
3. Do you own any_cash, or do you have money in checking or savings accounts?
Yes lj No I] {Include any funds in prison accounts.)
‘ lf thrianswer is "yes," state the total value of the items owned.
I7‘°`-‘? t‘>~)c:».·;t:;¤_>,c§r
` 4. Do' you ownror have any interest in any real estate, stocks, bonds, notes,
automobiles or other valuable property (excluding ordinary household furnishings
and clothing)? I
Yes I] No lj
. lf 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. high);
I declare under penalty of perjury that the foregoing is true and correct.
with ’ ' "
Executed on V -“•• · · ¤¤· 9 — l°'
(Date) Si r_. - of Applicant
CERTIFICATE
(Prisoner Account; Oniy) W V
I CBI'I.Ify that the applicant nz ed h&I’€IIt I't&S I ‘ 5 Im of . I A
on account to his credit at the · _ A . .... \ A ¢¤.lHn".!*lI![I!E§n' A . ‘
institution where he is confined. I further certify that the a plicant likewise has the following securities to
his credit according to the records of said institution:
I further certify that during the last six months the appIicant's aver
Authori Officer of Institution
‘ · _· I ' 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-
.` ity therefor. .
United States Judge one loaned States page Date
or Magistrate

Case 1:04-cv-00241-GMS

Document 22-2

Filed 12/01/2005

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Case 1:04-cv-00241-GMS

Document 22-2

Filed 12/01/2005

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