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

Case 1 :07-cv-00378-JJF Document 1 Filed 06/12/2007 Pe gg Q I 2
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DISTRICT OF DELAWARE " I i
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Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
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I, {IQ M E Q declare that I a.m the (check appropriate box)
% 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 thatl am entitled to the relief
sought in the complaintfpetition/motion. .
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? El Yes gblo (If "No" go to Question 2)
If "YES" state the place of your incarceration '
Inmate Identification Number (Required):_r_
l y' i Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet giorn the institution ot your incarceration showing at least the gast sb: months ’
transactions - - R `
2. Are you currently employed? Er Yes E No
a. If the answer is "YES" state the amount of your talozyme salary or wages and pay per`od a
and give the na.me and address of your employer. 6 J;//JIM
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b. If the answer is "NO" state the date of your last em{I1`E1y1ne1f$%1e‘§¤1gunt’cg` take%m%/Z/{
salary or wages and pay period and the name and address of your last employer.
3. In the past l2 twelve months have you received any money from any of the following sources? l
a. Business, profession or other self—employment El Yes jx No
b. Rent payments, interest or dividends El Yes .E|L~No
c. Pensions, annuities or life insurance payments E1 Yes ,E‘LNo
d. Disability or workers compensation payments El Yes El-No
e. Gifts or inheritances E1 Yes B2 No
f. Any other sources El Yes gd No
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-00378-JJF Document 1 Filed 06/12/2007 Page 2 of 2
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4. Do you have any cash or checking or savings accounts? U Yes jilslo
lf "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
valuable property?
U Yes gil No
If "Yes" describe the property and state its value.
6. 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 information is true and correct.
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DATE A SIGNA A ANT
NOTE TO PRISONER: · A Prisoner seelring to proceed without prepayment of fees shall submit an
afiidavit stating all assets. In-addition, a prisoner must attach a statement certiiied by the appropriate
institutional ofiicer 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 certiiied statement of each account.