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

Case 1 :08-cv-00341-JJF Document 10 Filed O9/05/2008 Page 1 of 2
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UNITED STATES DISTRICT COURT 6
DISTRICT OF DELAWARE Fo I **`
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Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
A [ Q tz-? C¤..$·:(’é Cot..,Q·L¥ FEES AND AFFIDAVIT
Det`endant(s)
CASE NUMBER; *3 ll (
l, 2 0 JQ. {Q 6 · S L ' Q LQ X declare that I am the (check appropriate box)
Q Petitioner/Plaintiff/Movant D Other
in the above—entitled 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, I answer the following questions under penalty of perjury:
l . Are you currently incarcerated? D Yes genie (If "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identification Number (Required):
Are you employed at the institution? you receive any payment from theinstitution? A [ O
Attgch a ledger sheet [rom the institgion gt your lncargeggtign detailing all gransgctions gver the past
six months.
2. Are you currently employed? El Yes SQ No
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period
and give the name and address of your employer. C)
b. If the answer is "NO" state the date of your last employment, the amount of your take-home
salary or wages and (pay period and the name and address of your last employer.
3. In the past l2 twelve months have you received any money from any ofthe following sources? IQ. yyy+.
a. Business, profession or other self—empl0yment SQ) Yes l Q No 6 6 O O
b. Rent payments, interest or dividends el ¤ Yes { (
c. Pensions, annuities or life insurance payments D Yes l
d. Disability or workers compensation payments D Yes S
e. Gifts or inheritances ¤ Yes $2
fi Any ot.her sources D Yes ‘ ¤
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 :08-cv-00341-JJF Document 10 Filed 09/05/2008 Page 2 of 2
Case 1:08-cv—00341—JJF Document 5 Filed 06/10/2008 Page 2 of 2
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4. Do you have any cash or checking or %ings accounts? D Yes we
if "Yes" state the total amount $ Z L ‘ O U
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘
·- ‘ kl Yes E No
If "Yes" describe the property and state its value.
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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.
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I declare under penalty of perjury that the above information is true and correct.
DATE SIGNATURE OF APPLICANT
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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.

Case 1:08-cv-00341-JJF

Document 10

Filed 09/05/2008

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Case 1:08-cv-00341-JJF

Document 10

Filed 09/05/2008

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