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

P Case 1 :07-cv-00788—Gl\/IS Document 5 Filed 12/20/2007 Page 1 of 3
40 2{0 10/03)
5/05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
‘ ‘ .
x. QS; `· . ‘xx.§;. —-
rmnnrr APPLICATION TO PROCEED
V. _ _ WITHOUT PREPAYMENT OF
§Q__\@g S \—X$~\\ $\-OQ y FEES AND AFFIDAVIT g
Defenclant(s)
CASE NUMBER: Civ Action 07-788 GMS
I, Kd.? S __ .» _ P O A declare that I a1n the (check appropriate box)
é` Petitione ovant E Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l915, I declare that I am unable to pay the costs of these proceedings and that I am entitled tothe relief
sought in the complaint/petition/motion.
Insupport of this application, I answer the folging questions under penalty of perjury:
l. Are you currently incarcerated'? . Yes D No (If "No"- goto Question 2) i
If "YES" state the place of yourPincarceration* . r A \ · P · P . · . `D .‘- ·\e*\P! P
Inmate Identification Number (Required): ` 5 Q >l Q 5 Q
Are you employed at the institution? me you receive any payment from the institution?®_@
Attach a tedger sheet [rom the institution of your incarceration detailing all transactions aver the ggast
six months. &' A
2. Are you currently employed? E1 Yes No
a. If the answer is "YES" state the amount of your takeehome salary or wages and pay period g ·
and give the name and address of your employer. l
b. If the answer is "NO" state the date of your last employment, the amotmt 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 self-employment E1 Yes @/ No
b. Rent payments, interest or dividends M q H El Yes E1] No
_ ‘ c. · Pensions, annuities or life insurance payments P · A _ U ° Yes ` ` No . Q
I d. Disability or workers compensation payments El Yes S1) No I
e. Gifts or inheritances P E1 Yes _ » No
f. Any other sources g El Yes B-/I No `
If the answer to any ofthe above is_"YES" describe each source of moneyand state the amount
received AND what you expect you will continue to receive.

Case 1 :07-cv-00788—Gl\/IS Document 5 Filed 12/20/2007 Page 2 of 3
Cb n
A0 240R¤verse(Rev. lo/D3)
DELAWA1iE!R_25/U6!
4. Do you have any cash or checking or savings accounts? D Yes J No
If "Yes" state the total amount $
,5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other I
Y valuable property? U J
El Yes No
If "Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state your relationship to each person and . r
indicate how much you contribute to their support, OR state NONE if applicable. W
. 6\O€]({__\’\@s QY\Q»&€Z>`€\ \i R`\"\k\ xi \ bs\€»· —is—§·~,·@__.Q·
l . ¤$\s><‘<¤ .<;\ QN"` U\ SQ ` " `ir Q®‘\°‘*°\ mgm yg .&>€.)(Q§O (ds §{`"s€·i$l°`\(·J\ QDCK) €·?.,,,\__)(;("‘r_)\
©.t_.._g,.._Q,~Q ~%·e»e,$ ~.
I declare under penalty of perjury that the above information is true and correct. U
- " .
h)··—‘ it 7 * @47 GQQ i ni ‘ -» s.;-ee ·· st. -Q A ··
DATE SIGN ¥" URE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit r ‘
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
officer showing all receipts, expenditures, and balances durin 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. i
i
l

Case 1·07
- ·C - -
v 00788 GIVIS Document 5 Filed 12/20/2007
Page 3 of 3
_-'7. Y}i;1;*?*°·’%"¥ —'“· ‘“~‘7- ¥/_‘ `
*.1 , ;
é ' i é ~
, V, .V . ;_ it '· — ’ » €
i ._.-¤,, ay
3 %‘ ·1¢ ‘4·» ·‘ fg;. `1 _7 i 7
7 7 _§gVV,_%; W.
¤ » ·~·»¥j,; 7 ,,5. 77
V, ·4!' · 9,* .
t ~ . FV Mme: 7
7 ‘ g=:=;»27`% M, E 7
7 ' ` #-·~·~;¥ `ixgi Q ·»·§· Y V
7 _ V V 7 vi ·
. ,.-¤;mq4%QT: QM); VV ,
gl ( ‘ "’& V
7 > . · {**-5 ;\ ..7*1 kh! { NB, I {gl · I- qi
3 V w ‘ - J .·¢ V. V . ”
I V `V gm; ,;¤»#¢*' 7 V
E , g { 7 _ ’ ‘ ` ’ é' ` .` .
3 M, ‘ ""r Q {*3 Q 2.
7 1 il.! . V" ·"_ J 9* -:2 7 7
Q °* 7» - ? s e ,..·»· F gg 7 ‘
7 € ` ` " "' .···¤’·`
• . : V {ak _7 ky VV__;;,V f _ 7
!’** » ?
` · = r* A" » W/·~*"” 7
i ‘ F" {zi ` 7 7 ” » ·‘ `
L {Vx X ._ ·~£ V V_!,..»
’ _ J ,~ .1* by -f »-J: 8
‘ ` ·· · S? iz/· { A`:
' ` V 7**; _; V ·_VVL
] A {V V; · '>· if ` :1;*
é ·· Qf 5*72 > -
. “ Y 9 ` ‘ *·»· 3 L.··»¤= -cv-¥ e
I I-5 V .{•_1Z ·Z;
. "? ¤7 *°”m*·"" if? V [ ·
* ‘~ `*$' 47* `:="‘* — `
7 _ · ' '"_V,.» 13**
. FV V V »· V VVVV_.»~*; arf _V {
A ` Lé ,J?—L {*3
é “ CL —r;’ “‘ A ..»¢’/ ·=§·:
g ,/{ V V
7 - · i 2\»··»·* V I3.! - .
i VV; ul V
. ° V 1 · ‘ 3
> >· l ~»j·;""i—· ¢
* [gg 7 7
,»/‘ , ji? V 7 ge
V 3 yy; ea *—·*‘ iz 7 ‘
· 3 W a;‘1*""‘ ‘"V g ?
VV,· ’ » . V V V {4% `
7 7 ,7 .:.8 ¤.~
_ sl V § »· ` , 57 Q L .
` · { M V/{3 C3 : · _
2 " , TM ‘ if

Case 1:07-cv-00788-GMS

Document 5

Filed 12/20/2007

Page 1 of 3

Case 1:07-cv-00788-GMS

Document 5

Filed 12/20/2007

Page 2 of 3

Case 1:07-cv-00788-GMS

Document 5

Filed 12/20/2007

Page 3 of 3