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

Case 1 :07-cv-00378-JJF Document 8 Filed O9/24/2007 Page 1 of 2
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· i UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
1._E V. WITHOUT PREPAYMENT OF
to /42 raw
/ / J /" FEES AND AFFIDAVIT
Defendant(s)
R CASE NUMBER: - 89
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L l . ‘· I declare that l am the (check appropriate box)
g Petitioner/Plaintiff/Movant El Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion. . fg Gil?
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In support of this application, I answer the following questions under penalty of perjury: rtg l.£?’>’.TI
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l. Are you currently incarcerated? Cl Yes glide (lf "No" go to Question 2® Girri
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If "YES" state the place of your incarceration P —· ` EET
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Inmate Identification Number (Required): J "‘“
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Areyou employed at the institution? Do you receive any payment from the institution?
Attach a fed er sheet om the institution o our incarceration showin atleast the ast six rnonths’
transactions
2. Are you currently employed? /ElC` Yes El No
EL If the answer is HY]-35** State the amount of your ralqe-hgpp/sa§.r:?y;org;rages and pay period a
an give ie name an a ress o your cmp oyer 2552 i ff- / _ jzgzti
a ‘ ri ri as r 1 ‘ . ·' * ... I ,
b. lf the answer is "NO" state the date of your last employnéit, t e amolgifyour take-home $6/
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 of the following sources? U
a. Business, profession or other self-employment EI Yes A E1 No
b. Rent payments, interest or dividends D Yes El No
c. Pensions, annuities or life insurance payments E1 Yes Cl No
d. Disability or workers compensation payments El Yes El No
e. Gifts or inheritances El Yes E1 No
f. Any other sources p D Yes U No I
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.

Case 1 :07-cv-00378-JJF Document 8 Filed O9/24/2007 Page 2 of 2
A0 240 Reverse (Rev, ltu'03)
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4. Do you have any cash or checking or savings accounts? D Yes } lt` "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? _
lil Yes $@10 .
If "Yes" describe the property and state its value. I
i t 1 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. , ·
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I declare under penalty of perjury that the above infomation is true and correct.
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· ATE ` '·l • ‘ LICANT l
NOTE TO PRISONER: · A Prisoner seeking to proceed without prepayment of fees shall submit an
affidavit stating all assets. Inaddition, 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. If you have multiple accounts, perhaps because you have been in multiple
_ institutions, attach one certified statement of each account.