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

H I an A Case 1 :07—cv—00788-GI\/IS Document 1 Filed 12/05/2007 Page 1 of 2 .
} so 2dU {Rev. 10/:1:,) I U I I.
DELAWARE gev. 4015 ‘ ’ =
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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y risratirr APPLICATION T0 PROCEED
v. `WITHOUT PREPAYMENT OF
‘fss $5 ,, 3; so {Las TE, FEES AND AFFIDAVIT
Defendant(s) . _ _ ,
cass NUMBER; CAF'] E`?
I, `°\*:=~.E`§**§ fag; Ei ifit, ‘·~.g¤~¤ f§&_ declare that I am the (check appropriate box)
· • . . ‘·=**?’"'“"`°`I°“‘*=_ · • '
Petitioner/§kiEPi;i4t¤i‘t*`§{Movant Other
inthe above-entitled proceeding; that in support of my request to proceed without pr .. ~ ---- - ;- o-rr -in-c — .-,
28 USC §l915, Ideclare thatI am unable to pay the costs of these proceedings an thatl am . t is Ei relief
sought in the cornplainupetinon/motion. I I A 1
I I DEC — 4 2007 p
In support of this application, I answer the following questions under penalty of pe : _ g _____ _ M an t .
l, Are you currently incarcerated? ° §;£*9 I •N0 (If"N¤" $0 0
If "YES" state the place of your incarceration \;\ ;Q.>‘···· ~ r <·--r ° Q
Inmate Identification Number (Required) za j ‘.·
Are you employed at the`institution?Q;§Q_ Do you receive any payment from the institution? l
l Attach a ledger sheet pjorn the institution of your incarceration showing at least the gast six: mont}zs’
transactions __ ___g gg__ -
2. Are you currently employed? ° Yes ` Y U ° ® -
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. I -
b. If the answer is "NO" state the date of your last employment, the amount of your tal salary or wages and pay period and the name and address of your last employer.
3. In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment • • Yes = · • No
b. Rent payments, interest or dividends • • Yes _ • No
c. Pensions, annuities or life insurance payments · • Yes • • No
d. Disability or workers compensation payments S • Yes · No
e. Gifts or inherltances { tgp; s · • No Y
f. Any other sources • · Ye ` • • No
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. @)g_¢=e·,Le%_st,§Q_y
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r , Case 1:07-cv-00788-Gl\/IS Document 1 Filed 12/05/2007 Page 2 of 2 *‘
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AO 2-4U Reverse (Rev, 10/03) l
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l 4. Do you have any cash or checking or savings accounts? • • Yes •®
If "Yes" state the total amount $ ’
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? i _
g · · Yes Qg
g If "Yes" describe the property and state its value.
2 ··‘· 6. List the persons who are dependent on you for support, state your relationship to each person and
` A indicate how much you contribute to their support, OR state NONE if applicable.
‘.isQ'*Z\ ~·,°:@`·i‘·~·?‘·ii..____ YFQQWM . 11<»~e{j;\.t“e<.€,,_. `
C iv. ye"
U _§TGr;j5_;, Qsts —`¤·e"·e»e,,a ~‘-:·=€L¤»tK3\ei-i' @~%"<> Q,\<;>·`rlr\€... ··l~e»\·~,e,,icv:·~·,
Z p Ideclare under penalty of perjury that the above information is true and correct, `
I`- -' . z=.t , _R$_g_ litr lnsiigq _?_ r- ,· _
g >‘ ;\\ " Q i, _ ‘.‘ .
1 , DATE 2 2 SIGNATURE OF APPLICANT
l I NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an aftidavit
I ; stating all assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional
§ — ofticer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
1 I If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certiiied
\ statement of each account.
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Case 1:07-cv-00788-GMS

Document 1

Filed 12/05/2007

Page 1 of 2

Case 1:07-cv-00788-GMS

Document 1

Filed 12/05/2007

Page 2 of 2