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

_ AO I D mCase 1 :07-cv-00405-JJE Document 4 Filed 06/21/20.07. Page 1 of 3
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UNITED STATES DISTRICT COURT
` DISTRICT OF DELAWARE
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C M 5 _ Plain rr ` APPLICATION TO PROCEED
' ' v_ Gods €»·\·=-¤W`3• WITHOUT PREPAYIVIENT OF
Baines M FEES AND AEEIDAVIT
Defendant(s) @¤~*“" . as ___ .
`I CASE NUMBER: U { A O 5
I, { B declare that I arn the (check appropriate box) U
°& Petitioner/Plaintiffr%/Iovant ° ° Other me
in the above-entitled proceeding; that in support of my request to proceed without prepa en l”I€I‘T逧`§E6`sts under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and t tI Br en5ipl§3ri.t;ri»§11?Gnjpef l
sought in the petition/motion. l " L * ‘ A E
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I In support of this application, I answer the following questions under penalty of perjury}! dm- · ~ l
l. Are you currently incarcerated? ‘?‘Tes ° °No (If "No" go to Question 2)
. If "YES" state the place of your incarceration §§§;g)(),5]ji - \'Ig;¤;%; gjj I
Inmate Identi1Ication Number (Required); dl 2) Z I .
l Are you employed at the institution'? _Ll_Q Do you receive any payment from the institution? _l\__lC)_ l
I Attach cz Ierilver sheer Qom the insritzrnon of`votre·incc1r.:er;iri0.·r showirzgrzt letrsttlre nas! str mo.»it}1s'
transactions ·
2. Are you currently employed? ° ° Yes °q?r' - -
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. |Q cp M L
b. If the answer is "NO" state the date of your last employment, the amount of your take-home U
salary or wages and pay pegod and the name and address of your last employer. \\DmL
R V5 3* Kg _ L/90,60 per w·.»;s,\c.
3. T In the past l2 twelve months gre you received any money from any of the following sources?
a. Business, profession or other self-employment · · Yes I *dV<
b. Rent payments, interest or dividends I ‘ · • Yes 7%
c. Pensions, annuities or life insurance payments · • Yes ·¢’§d
d. Disability or workers compensation payments · • Yes 7"lq
e. Gifts or inheritances · • Yes
f. Any other sources · · Yes · fé i
If the answer to any of the above is "YES" describe each source ofmoney and state the amount
receivedAN]D what you expect you will continue to receive. IQ O P3 {W

,_ · Case 1 :07-cv—0040§-JJF * Document 4 _ Filed 06/21/2007 Page 2 of 3 . a
I AO 214] Reverse {Rev. KUIOJ) -
DELAWANE {Rav. UGS ' - l .
l 4. Do you have any cash or checking or savin s accounts? •l· Yes $1 No
If '*Yes" state the total amount $ ‘ _ ·
-5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
_ valuable property? ‘
· • Yes °(N·6
i U If "Yes" describe the property and state its value. I l `
‘ 6. List the persons who are dependent on you for support, state your relationship to each person and _
_ indicate `now much you contribute to their support, OR state NONE if applicable.
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_ I declare under penalty of perj e above information is true and correct.
J- J ‘ · - —» ._____
DATEp p, i-*‘ ` · SIGNATURE OF AP ANT ` _
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of tees shall submit an affidavit
e stating all assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional
officer showing all receipts, expenditures, and balances during the last si; months in your institutional accounts.
H you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account. ‘ _ `

Case 1 :07-cv—00405-JJF Document 4 Filed 06/21/2007 Page 3 of 3
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