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

Case 1 :07-cv-00783-JJF Document 5 Filed 12/O3/2007 Page 1 of 2
AO 24lZl [Rev.10/U3)
DELAWARE [Rev. dg B52 V
UNITED STATES DISTRICT COURT .c 0 "{ "' _] 8 3
DISTRICT OF DELAWARE W
. ·rl s _ ‘ ` " I
liogl o umm S
by C . _ Plaintiff ff, / _ Z DOA?/APPLICATION TO PROCEED
."@<> ”' 1’*~°"§»0~» ’""* @*1%** ~©?di“ ' "’ ~ ”"—" "` # N J » WITHOUT PREPAYMENT or ·
lléluxfél I 5%%% Com M./·aid# Comec aw al @#6/ C'- . 9 FEES AND AFFIDAVIT l
R . Crm] Cal 1/aa'? Goal <~ ¤Q£i%2%¤'j‘(% Mme; 722 wawaq/C’;’@”g“”5 ER.
A I, 'J J I UUQU"? 5 . declare that I am the (check appropriate box) U
<"‘r— `* ...»-- ` .
l ' /PetitionerfI{lrdn—tif`f7'l`}ib‘vant {Ether - i
" ' I`
` int e - 1 e proceeding; that in support of my request to proceed without pre ‘’`‘ E ';‘‘
28 USC ·§19l5, _I:dec;lare that I am unable to pay the costs of these proceedings hat _
sought in th etitionfmotion. ’
is
In support of this application, Ianswer the followiiyuestiom under penalty of perj : ___, __ __ , __ ”__1 ·= 5 l
E Ll? fill? ini? ·" ***1
1. Are you currently incarcerated? Wes ° °No (If "No" go digg; _
If "YES" state the place of your incarceration nl VO ‘
l Inmate Identification Number (Required); Q 8 / 5];-
‘ Are you employed at the institution? MZ 0Do you receive any payment from the institution? MO
Attach cr led er sheer rom the irzsriturion 0 our incarceration,showz`n atleast the ast six mom‘hs'
transactions ‘ /~/l’li'
2. Are you currently employed? ' ° Yes ° ·/No

p 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. ,,\d{/4;
b. lf 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 I2 twelve months have you received any money from any of the following sources? `
a. Business, profession or other self-employment · · Yes vw!
b. Rent payments, interest or dividends · · Yes ·/{
c. Pensions, annuities or life insurance payments · · Yes ·/>(o
d. Disability or workers compensation payments • · Yes • f<’€ .
e. Gifts or inheritances · · Yes ·;‘/go
f. Any other sources · · Yes ’p o
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.

Case 1 :07-cv-00783-JJF Document 5 Filed 12/O3/2007 Page 2 of 2
AO 240 Reverse (Rev. 1D/03)
DELAWARE lllev. ·I£'03
Y4. Do y_0u have any cash or checking or savings accounts? · • Yes VK _ l U
. lf "Yes" state the total amount $ Q l Y -
T 5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or er 3 _ .
· ‘_ valuable property? t I ·
` · • Yes • 0 ,
lf "Yes" describe the property and state its value.
p Y Y Y -- YY Y ···· jj T Y
Y Y 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.

I declare under penalty of perjury that the above information is true and correct.
/{{'9`CéI[ ( —
DATE ‘ SIGNATURE OF APPLICANT
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 appropriateinstitutional
offieer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
II you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.

Case 1:07-cv-00783-JJF

Document 5

Filed 12/03/2007

Page 1 of 2

Case 1:07-cv-00783-JJF

Document 5

Filed 12/03/2007

Page 2 of 2