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

Case 1 :07-cv-00766-JJF Document 1 Filed 1 1/O2/2007 Page 1 of 2
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UNITED STATES DISTRICT COURT
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- Piaartrr APPLICATION TO PROCEED
__ V. - · WITHOUT PREPAYMENT OF
(§,;,;Q.g,,£e£,- Q and £,·g_e< Q¤,m_a·S ~ FEES AND AFFIDAVIT
Defendant(s)
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L Q gmaag QQ? lA,~¤¤;_a; 5.; “ declare thatl am the (check appropriate box)
° ° Petitioner/PlaintifD'lvIovant ° S Other
in the ab ove-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §19'l 5, I declare thatl am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintipetitionfmotion. 5
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? ° ° °No (If "No" go to Question 2)
If "YES" state the place of your incarceration 3 gag; gu" nm ,,g,r..§ gg g§g&r;Q,n§ (Lease;
Inmate Identification Number (Requiredyg,. rg, -;*’· 3311SQ
Are you employed at the institution? we `Do you receive any payment from the institution? gp;
Attach cz ledger sheet {rom the institution of your incarceration showing or feast the gust six m_.gnths’
transactions ·
2. Are you currently employed? ° °Yes °
_ 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.
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 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment · • Yes ·
b. Rent payments, interest or dividends · • Yes ·
c. Pensions, annuities or life insurance payments • · Yes ·
d. Disability or workers compensation payments · · Yes - _
e. Gifts or inheritances • • Yes ·
f. Any other sources · · Yes ·
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-00766-JJF Document 1 Filed 1 1/O2/2007 Page 2 of 2
AO 240 Reverse [Rev. 10/ CG)
DELAWARE£Rev. 4fl}5l
4. ` Do you have any cash or checking or savings accounts? - • • Yes · (•Noi A
l ` If "Yes" state the total amount Sp ggcml;
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
` · _ valuable property? I ` '_ .- ` ` `
` · • Yes
If "Yes" describe the property and state its value.
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6. List the persons who are dependent on you for support, state your relationship to each person and
U indicate how much you contribute to their support, OR state NONE if applicable. mw;

. I declare under penalty ofpeijury that the above information is true and correct.
-J ‘ **8 #07
DATE SIGNATURE OF APPLICANT I
NOTE T0 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
officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
Ifyou have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account. _ _

Case 1:07-cv-00766-JJF

Document 1

Filed 11/02/2007

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Case 1:07-cv-00766-JJF

Document 1

Filed 11/02/2007

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