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

. _ A, my RE In mCase 1 :07-cv-00405-JJF Document 3 Filed 06/21/2007 Page 1 of 3
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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e Ptatnn ,3. FW:) Nr.e_;atv1q.¤ APPLICATION TO PRO CEED
_ g Carl U -Dmbg/. _ U` _ WITHOUT PREPAYMENT OF
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Defendant(s) Q . l .
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I, if ` § g % l(»( declare that I the (check appropriate box) .
° Petitioner/Plaintiff!}/Iovant ° ° Other ‘ s “` M ”” i
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inthe above-entitled proceeding; that in support of my request to proceed without p iepa i ent of fees or costs thier
28 USC §l9l5, I declare that I am unable to pay the costs ofthese proceedings . ri thai Iaripl gptigerl re of
Sought in the ennon/menen. . y ’“ " A i
‘ kl Suvimtt Of this ¤1¤pli¤¤ti¤¤,1answ<=r the folio? questions Linder penalty of pe Q t .... .... naa-
l. Are you currently incarcerated? ° A "es ° °No lIf"No" go to Question 2)
. If"Y`ES" state the place of your incarceration PA UAE; GOJY ` Ing";
l Inmate Identification Number (Required); Ti
`Are you employed at the institution? No Dc you receive any payment from the institution? N0 i
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2. Are you currently employed? ° ° Yes ° o l .. · .
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. N cme-
b. If the answer is "NO" state the date of your last employment, the arnoimt of your tal _ salary or wages and pay period and the name and address of your last employer.
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3. T In the past 12 twelve months have you received any money from any of the following sources? A
_ a. Business, profession or other selt`-employment · • Yes @
b. Rent payments, interest or dividends A _ ` l • · Yes 1 • N
c. Pensions, annuities or life insurance payments l • · Yes &
d. Disability or workers compensation payments · • Yes Lila
e. Gifts or inheritances _ • • Yes · • No r
f. Any other sources · • Yes A `
If the answer to any of the above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive. [N q5»[\·Q

_ . Case 1. :07-cv—0040§-JJF* Document A3 , Filed 06/21/2007 Page 2 of 3 » . ‘
AD MG Reverse (Rev. 10,/00} -
DELAWARE {Rev. -l/'D5} r ~
i 4. Do you have any cash or checking or savings accounts? · · Yes ,/· ·;¤/
If "Yes" state the total amount $ .1‘ _c_ p _
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
_ valuable property? ‘ ‘ lf
• • Yes • • 0
` _ If "Yes" describe the property and state its value. . · l
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6. Iiist the persons who are dependent on you for support, state your relationship to each person and i
indicate how rnuch you contribute to their support, OR state NONE if applicable. _
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_ I declare under penalty of perjury that the above inforrnation is true and correct.
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DATE i 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 certitied by the appropriate institutional
officer showing all receipts, expenditures, andbalances during the last si; 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—00405-JJF Document 3 Filed 06/21/2007 Page 3 of 3
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