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

t Case 1 :07-cv-00814-GI\/IS Document 1 Filed 12/12/2007 Page 1 of 2
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE p
CLARENCE EDWARDS
Plaintiff, APPLICATION T0 PROCEED
v. WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
ICATHLEEN AMALFITANO ET AL.
_ Defendant(s) CASE NUMBER: _
I, declare that I am the (check appropriate box) ”` 0 7 — 8 1 4 —·—
_ E Petitioner/’Plai11tif§’I\dovar1t I;] Other . p
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? n E Yes I;] No (If "No" goto Question 2)
If "YES" state the place of your incarceration DELAWARE CORRECTIONAL SMYRNA DELAWARE
Inmate Identilication Number (Required): 158551
Are you employed at the institution? Yes Do you receive any payment from the institution? Yes
Attack a ledger sheet {crm the insttttttion of your incarceration showing. at lemt the past sir months ’
transactions
2. Are you currently employed? IE Ym I;] No
a. It` 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. 10.00 M'I'I-I.
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 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other se1f—empl0yment I:] Yes E No
b. Rent payments, interest or dividends I;] Yes IZI No
c. Pensions, annuities or life insurance payments I:] Yes EI No
d. Disability or workers compensation payments I;] Yes IE No
e. Gifts or inheritances I;] Yes E No
tI Any other sources " I;] Yes El No
If the answer to any ofthe above is "YES" describe each source of money and state the amount received AND what you
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DELAWARE (Rev. 4105)
4. Do you have any cash or checking or saving accounts? EI Yes E No
If "Yes" state the total amount EB 0000
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? I:] Yes E No
If "Yes" describe the property and state its value. p
00000. p _
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.
_ NONE.
I declare under penalty of perjury that the above information is true and correct.
. //17-07 gpgfglggrdg 3 .
DATE . SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an afndavit
stating all assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional
olticer 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 certihed
statement of each account.

Case 1:07-cv-00814-GMS

Document 1

Filed 12/12/2007

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Case 1:07-cv-00814-GMS

Document 1

Filed 12/12/2007

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