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

_ Case 1:08—cv—00159-Gl\/IS Document 1 Filed 03/20/2008 Page 1 of 2 _
AO {Rev. 10/03]
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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_ Plaintiff APPLICATION TO PROCEIEQ
V. _ WITHOUT PRCPAYMENT QQ,
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Defendant(s) · . “‘
case NUMBER; 0 8 r 1 5 9
I, Us I iii;} riitii L§§’2..‘gj1¤·,?;.i A declare that I am the (check appropriate box)
° ° Petitioner/PlaintifffMovant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
A 28 USC §l915, Ideclare that I arn 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 follo ' question .-ew ¤. penalty ofpeijury;
J' V _ _ _ ’ .
' 1. Are you currently incarcerated? ° (If "No" go to Question 2)
If "YES" state the place of your incarceration ri
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Inmate Identification Number (Required): Gigi; liu X;} 3 Q
Are you employed at theinstitution? .»`¤‘ Do you receive any payment from the institution? NAU l
l Attach a ledger sheet Qom the institution of your incarceration showing at least the past sb: rnont}zs’
transactions _
2. Are you currently employed? ° ° Yes A @p,.»’;
a. If the answer is "YES" state the amount of your take—home salary or wages and pay period a A
and give the name and address of your employer. I
bf Ifthe answer is "NO" state the date ofyour last employment, the amount of your take-home
salary or wages and pay period and fthe name and address of your last employer.
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3. In the past l2 twelve months have you received any money from any ofthe following sources?
U a. Business, profession or other self—ernployment - · Yes · l
b. Rentpayments, interestor dividends · • Yes · r_,__
c. Pensions, annuities or life insurance payments { · • Yes ·
d, Disability or workers compensation payments • • Yes · gg)
e. Gifts or inheritances • · Yes · No?
f. Any other sources · · Yes · {Nd
If the answer to any ofthe 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-00159-GIVIS Document 1 Filed 03/20/2008 Page 2 of 2 ,_
AO 24U Reverse [Rev. ID,/D3)
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l 4. Do you have any cash or checking or savings accounts? ' • Yes
If "Yes" state the total amount S Q Ci ‘
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘ gx
• • Yes oi
If "Yes" describe the property and state its value.
V {IU LQ: 1 .
6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how much you connibute 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.
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DATE I SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of [ees shall submit an affidavit
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
officer showing all receipts, expenditures, and balances during the last six montl1s in your institutional accounts.
Il` you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement ofeach account.

Case 1:08-cv-00159-GMS

Document 1

Filed 03/20/2008

Page 1 of 2

Case 1:08-cv-00159-GMS

Document 1

Filed 03/20/2008

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