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

D _ Case 1 :07-cv-00413-JJF—I\/IPT Document 1 Filed 06/25/2007 Page 1 of 2
JUNE 20 2007 WED FILED VERY HONORABLE CHIEFPJUDGE ROBINSON
i 0 T ·· 4 1 3
` IN FORl\/IA PAUPERIS DECLARATION _
_ D DEL U S COURT _
l _ ~ [Insert appropriate court] _ _ ·
STATE OF D DEL EX REV V GADSON DECLARATION HV SUPPORT
- (Petitioner) QF REQUEST
CEO _ EXPORT & IMPORT ET AL [N }•£?) Cf}F,§:'[?[3ER]S
1$Respondent(s))
GADSO - . . . .
I, , declare that I am the petrinoner 1n the -above entitled case; that
in support: ar my motion to proceed without being required to prepay fees, costs
or give security therefor, I state that because of my poverty, I am unable to pay
‘ the costs of said proceeding or to give security therefor; that I believe I am
entitled to relief.
.. B Are you presently employed? Yes Q No
O T A 1 . ,, ,,
__ _ _ _ a. If the answer 1S yes, state the amount of your salary or wages per
month, and give the name and address of your employer.
I G $(4 {
; rmmagrl it °NE
i _ __ b. If the answer is "no," state the date of last employment and the amount
of the salary and wages per month which you received.
5;** ......l -....._...._ - - - l._. - -..._._..._. _ `
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Have you received within the past twelve months any money from any of
following sources? ‘
_ VP a. Business, profession or form of self—employrnent? Yes Q No [X]
R eg; b. Rent payments, interest or dividends? Yes Q No [lf]
l c. Pensions, annuities or life insurance payments? Yes Q No
· l*· ··· rr" ' ‘‘‘ d. Gifts or inheritances? ‘ Yes Q No
e. Any other sources? Yes Q No Q '
If the answer to any of the above is "yes,” describe each source of money and}
state the amount received from each during the past twelve months.
_ 3. Do you own CBS), or do you have money in checking or savings account?
Yes Q No (Include any funds in prison accounts.)
n Ifthe answer is "yes,” state the total value of the items owned. mm

4. Do {ou own any real estate, stocks, bonds, notes, automobiles, or other
valuab e property (excluding ordinary household furnishings and clothing)?
Yes Q No KI
If the answer is “yes," describe the property and state its approximate
value.
5. List the persons who are dependent upon youfor support, state your
relationship to those persons, and indicate how much you contribute toward
their support.
I declare (or certify; verify; or state) under penalty of perjury that the foregoing
is true and correct. Executed on mn. (date). Q. ·
»
_ Signature of Petitioner
DATE FILED 6/20/2007

Case 1 :07-cv-00413-JJ§F¥I\/IPT Document 1 Filed 06/25/2007 P_age 2 0f 2
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