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

Case 1 :08-cv-001 10—GI\/IS Document 1-2 Fi '®§`i’]'l*’age 1 of 2
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-;’[‘fjj—i UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
_ _ lpiiliua APPLICATION TO PROCEED
y v. WITHOUT PREPAYMENT OF
____ FEES AND AFFIDAVIT
Defendant(s) . .-a ,.. A ; ` 5
CASE NUMBER: 0 8 1 1 0
I, _ s 1* _ .. ‘ si · declare that I am the (check appropriate box)
° ° Petitions ovant " ° Other
in the above·entitled proceeding; that in support of my request to proceed with_out prepayment of fees or costs under
28 USC §l915, [declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petitioulmotion.
In support of this application, I answer the following questions under penalty of perjury:
‘ l. Arc you currently incarcerated? ° @ ° °No "No" go to Question 2) h
If "Y`E.S" state the place of your incarceration _
Inmate Identilicatlon Number (Required):
{ Are you employed at thelinstitution? EO Do you receive any payment from the institution'? QQ A
Attach a ledger sheer Qom the iggstiturion of your incarceration showing or least the post six: months '
transactions
2. Are you currently employed? ° °Yes ` ° (Noi!
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a
and give the name and address of your employer. -
b. If the answer is "NO" state the date of your last employment, the amount of your take—l1ome
salary or wages and pay period and thejliame Bti; address of your last employer.
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- 3. In the past I2 twelve months have you received any money trorn any of the fcllgawingqs-`f>:°i\-aces. *7-% {
a. Business, profession or other self—employment · · No
b; Rent payments, interest or dividends • - es my
c. Pensions, annuities or life insurance payments • • Yes
d. Disability or workers compensation payments • • Yes
e. Gifts or inheritances · • Yes QW
f. Any other sources • • 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-00110-GIVIS Document 1-2 Filed O2/21/2008 Page 2 of 2
i Case 1:08-cv-OO110—Gl\flS Document 1 Filed 02/21/2008 Page 2 of 2 T
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i 4. Do you have any cash or checking or savings accounts? • · Yes l ·` · No >
If "Ycs" state the total amount $ ‘ ‘
5. Do you own any realestate, stocks, bonds, securities, other financial irtstrtunents, automobiles or other .
valuable property? e ‘ ` e ·
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Alf “Yes" describe the property and state its value. l
_ 6. List the persons who are dependent on you for support, state your relationship to each person and
p 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 infomation is true and correct. `
DATE i - _ J SIGNAQURE S-; APPLlCANii`
NOTE TO PRISONER: A Prisonei·`seeking`to proceed without prepayment ol' fees shall submit an affidavit l _
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
officer showin g 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 certiiied
statement of each account.

Case 1:08-cv-00110-GMS

Document 1-2

Filed 02/21/2008

Page 1 of 2

Case 1:08-cv-00110-GMS

Document 1-2

Filed 02/21/2008

Page 2 of 2