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

_, , Qasi1 :07-cv-OO784—Gl\/IS Document 1 Filed 12/O3/2007 Page 1 of 2
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r AO 240 (Rev. 10,·'[l3] A ‘ l
DELAWARE lRev. 4::05] :
UNITED STATES DISTRICT COURT ‘ I p
DISTRICTOF DELAWARE l
- Léi[afi9_!|;;g A}; /I/(cf I
p p ‘ Plaintiff . APPLICATION T0 PROCEED _ 1
. A V. V WITHOUT PREPAYMENT OF I ¤
. 2 / /[ 601*/T FEES AND AFFIDAVIT `
Defendant(s) ,. was
CASE NUMBER: ""’" O T T 8 A ,
I, °V A ` A declare that I am the (check appropriate box)
° lx Petitione ovant ° ° Other I E A . . 1... I I
A in the above-entitled proceeding; that in support of my request to proceed witho . prep · " • ’> - ‘ o cos s ` der ·
` 28 USC §19l5, I declare that I am unable to pay the costs of these proceeding and j· at I am entitled togihe ¤e·1ief p `
sought in the complaint/petition/motion. · _ J ·· 3 { . '
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p In support of this application, I answer the following questions under penalty of e u i'é·|$ §i§g.i Cg_? §|¤{ p_ 'p _ p l_ Q
1. Are you currently incarcerated? °& es ° °No (If "No" go to Questioni2) 1 ·
If "YES" state the place of your incarceration D; , ( és/0/ogg iM§ {MQ Z9? 27
Inmate Identification Number (Required): gl légg Z 5 ` _
Are you employed at the institution? 2 D0 you receive any payment from the institution? /i/Z Q
Attach a ledger sheet from the institution of your incarceration showing at least the past six months ’ U
transactions l l
2. Are you currently employed? ° ° Yes °i4lo
a. If the answer is "YES" state the amount of your take-home salaryior wages and pay period an 1
and give the name and address of your employer. i
- 1
l b. If the answer is "NO" state the date of your last employment, the amount of your me-homem ‘
salary or wages and pay period and the name and address of your last employer.
, _ l
3. In the past 12 twelve months have you received any money from any of the following sources? 1 a
A r a. Business, profession or other self-employment • • Yes at • %o `
` b. Rent payments, interest or dividends · • Yes •'2Io l
_ c. . Pensions, amiuities orlife insurance payments · • Yes U/No 1 l
d. Disability or workers compensation payments • • Yes ·‘/No i
e. Gifts or inheritances •_ • Yes • No .
f Any othersources •){Yes · • No l
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. . .
G't'0NéMOII\€*.\' Sendo 75 · IOC) cio//ctf’5_ wéemz Ver" ati/6., i
NO+ Feltictlyig 5Dt.>rcc·; CD; lNCc»ime_ _ . A

Case T:W-Ev-UO7$2i—GMS Document 1 Filed 12/O3/2007 Page 2 of 2
I AO 240 Reverse (Rev. 10/06)
DELAWARE Sgev. 4£05i · U
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A 4. Do you have any cash or checking or savings accounts? • · Yes ·[/Q>
If "Yes" state the total amount $ i
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5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
valuable property? / _
~ · · Yes · No ‘
i
If "Yes" describe the property and state its value.
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. I
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.
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I declare under penalty of perjury that the above infomation is true and correct.
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/ .- " if ./{ ‘``' " l Al" _____` ·
l DATE ‘ /_/»’ %~’ IGN s »»a"“l Q · PLICANT p _ " ·s·i~·- ». .
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
ofiicer 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 certified
statement of each account.

Case 1:07-cv-00784-GIVIS Document 1-2 Filed 12/O3/2007 Page 1 of 1
DELA WARE C ORRE C T I ONAL CENTER
SUPPOR T SER VICES OE F I CE
MEM ORAND UM I
TO: Q;-;i;g£;3A& { (/Ucuuie/1/SBI#.· 30ééL/3 C
FROM·" zqergtgd/{5 i/»<1.¢4tA/
RE: 6 Montlts Account Statement
DATE: lt ga e grr
. Attached are copies ofyoar inrnate account statementfor the months of
?V}a—;} @007 to 00,73 ber @002 . _ A
T he following indicates the average daily balances.
MONTH A VERA an DAILYBALANCE
C M Ag; [1/- ee
L, rf? //. 47
A _._5;1.Q.€=-........1 A
52:/· 43
Average daily balances/6 months: gk, 3 2, 50
Attachments _ A C
CC: File A # _ s_ I l
_ N , 4: ::.5
/7/JJ?/D 7 /,/9,/U ’ A

Case 1:07-cv-00784-GMS

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Filed 12/03/2007

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Case 1:07-cv-00784-GMS

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Case 1:07-cv-00784-GMS

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