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


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Date: March 20, 2008
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Category: District Court of Delaware
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_ Case 1:08—cv—00159-Gl\/IS Document 1 Filed 03/20/2008 Page 1 of 2 _
AO {Rev. 10/03]
nsorwiirta ga. ins;
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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_ Plaintiff APPLICATION TO PROCEIEQ
V. _ WITHOUT PRCPAYMENT QQ,
iii} 3 g rim 3 { (ifi-*”i 3 i FEES AND AFFIDAVIT ga AE
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.
em piey eil
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)
E’·"*"’·*“E "· * °5l .ee. 0 00 0 0 00 00 00 00 0 0 0 00 000 0 00 0 000 00. 0 00 00 00
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.
1I,l/QF
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

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Case 1:08-cv-00159-GMS

Document 1

Filed 03/20/2008

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