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

Case 1 :04-cv-00241-GMS Document 21 Filed 11/14/2005 Page 1 of 3
AO 210 (Rev. l0,·’UJl I
DEL»-\\'·'ARE Rev $/05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
, ~ ve. __». . . · — FEES AND AFFIDAVIT
Defenc1ant(s)
casa NUMBER; od cv · ·::·:>.9¢lt— Gmé
I, ‘ { ‘ *- . ‘ ~— , declare that Iam the (check appropriate box)
"L Petitioner/PlaintifD'Movant ° ° Other
in the above~entit1ed proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief . ..
sought in the complaint/petition/motion.
In support of this application, 1 answer the following questions under penalty of perjiiry: ‘ j
I. Are you currently incarcerated? °'/Yes ° °No (If "No" go t Que tion 2) _ _ g _ .
If "YES" state the place of your incarceration y t ___ ____t
5my y,=;,_>;~,, _ $$59) ;.:** ia=· c.,
Inmate Identiiicationl umber (Required): slr
Are you employed at the institution? jr!) Do you receive any payment from the institution'? igggé
Attach rt ledger sheet from the i'nstitt.ttiort of your incarceration showing ot feast the gust Sir months '
troiisactions
2. Are you currently employed? °`/° Yes ° No
a. lf the answer is "YES" state the amount of your take-home salarg or wages and pa period a
and give the name and address of our employ & · ‘*} e a ; _.,_p_s.. ,:2., ; 2
J? b. lfthe 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 of your last employer.
3. ln the past l2 twelve months have you received any money from any ofthe 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 •*( No
d. Disability or workers compensation payments · • Yes ·'*’No
e. Gifts orinheritances · · 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-00241-Gl\/IS Document 21 Filed 11/14/2005 Page 2 of 3
Certificate of·Service
GREGORY A. DENSTON _
I. , hereby cerzity that I have served a true
and correct cop(ies) of the attached: FORMA PAUPERIS
.. upon the following
parties/person (s):
TO: CI ERK QE THE Cmggy TO:
U - -
DISTRICT QE D·¤,],;;,ggg5·
‘ 8M-t KING STREET , LOCKBOX # 18
WILMINGTON, DELAWARE 19801
TO: TO:
BY PLACING SAME IN A SEALED ENVELOPE and depositing same in the United
States Mail at the Delaware Correctional Center, Smyrna, DE 19977.
On this 8TH‘ dey of NOVEMBER U . 2005
. [ t__I_

Case 1:04-cv-00241-G|\/IS Document 21 Filed 11/14/2005 Page 3 013
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Case 1:04-cv-00241-GMS

Document 21

Filed 11/14/2005

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Case 1:04-cv-00241-GMS

Document 21

Filed 11/14/2005

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Case 1:04-cv-00241-GMS

Document 21

Filed 11/14/2005

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