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

Case1:O7-cv—OO355-SLR D0cument5 Filed 07/O2/2007 Page10f4
‘ ‘ I
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
In Re:
` C.A. NO. 1: 07—cv—00355—SLR
Appeal: In Re: Atamian v. _
U.S. Department of Education ‘
MOTION TO PROCEED INFORMA PAUPERIS
COMES NOW plaintiff/appellant Gabriel G. Atamian,MD,MSEE, JD ,
moves this Court that in order to have the mandatory procedure
of mediation of appeals, the appellant has to file an Application
to proceed without prepayment of fees.
WHEREFORE, appellant prays this Court that the attached application
to proceed in Forma Pauperis will be granted ; and,_also, the fees
Of A smediatcrr Mr. Kevin Brady, to preceea without fees. AS
Respectfully submitted,
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Gabriel G. Atamian,MD,MSEE,JD 1J?)
1021 N. State Street Apt A
Dover, DE 19901
302-678-2546
Plaintiff/ Appellant. pro se
July 2, 2007 -
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PROOF OF SERVICE
I, Gabriel G. Atamian, do hereby certify that a copy of the
`hotion to Proceed InForma Pauperis and Application to proceed
without prepayment of fees and Affidavit, was served on July 2,
2007, postage prepaid, First Class US mail, on :
Ellen W. Slights V
.Assistant United States Attorney M A A G
1007 Orange Street, Suite 700 .
Wilmington, DE 19899-2046
Kevin Brady, Esq. .
The Nemours Building
1007 North Orange St. » _ ;», T
P.O. Box 2207 _
Wilmington, De 19899
Under penal ty of perjury, I declare that the foregoing is
true and correct.
, » 1p' z _ tn
K@f¤Qgg /hé)./"7}§;-;, J D
Gabriel G. Atamian,MD,MSEE,JD
July 2, 2007

- n . _ Case 1 :07-cv—OO355-SLR Document 5 Filed 07/O2/2007 Page 3 of 4
I
UNITED STATES DISTRICT COURT
THE Dist!-ict Of DELAWARE
Gabriel.G. Atamian, MD,MSEE,JD E3,
APPLICATION TO PROCEED 2
Plaintiff WITHOUT PREPAYMENT OF (5:;,
, FEES AND AFFIDAVIT i
. v' . A Re: Appeal M
U . S . Department of Education , F.,
’ , _ - _ Re: Appeal 3*1 ig;-A
- CASE NUMBER; Q?
Defendant: 1 ; 07 -ev-0 0 355-SLR i',
I, Gelbfi @1 G · Aliiimian · MD » MSEE » JD declare that l am the (check appropriate box)
K] petitioner/plaintifffmovant I] other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC §19l5 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/petitionfmotion. T
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? lj Yes lENo (If "No," go to Part 2) `
If "Yes," state the place of your incarceration
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet from the institutionisl of your incarceration showing at least the past six months’
transactions.
2. Are you currently employed? I] Yes . * No
a. If the answer is “Yes," state the amount of your take-home salary or wages and pay period and give the name
and address of your employer.
b. lf the answer is "No," state the date of your last employment, the amount of your taIte—home salary or wages
and pay period and the name and address of your last employer. I
1981, Howard University Medical School , Washington , DC U
Worked only 6 months . _ _
3. ln the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment I:] Yes ig No
b. Rent payments, interest or dividends Cl Yes IE No
c. Pensions, annuities or life insurance payments Cl Yes E No
d. Disability or workers compensation payments Cl Yes lil No
e. Gifts or inheritances E Yes I] No
f. Any other sources E Yes El No
lf the answer to any of the above is “Yes," describe, on the following page, each source of money and state the
amount received and what you expect you will continue to receive.

` I , __ Case 1 :07-ov—OO355-SLR Document 5 Filed 07/O2/2007 Page 4 of 4
AO 240 Reverse (Rev. 10:03)
3 Sw $550.00 gift from Dr. Richard Fuisz each month.
Dr. Fuisz and I, were interns at Cambridge City Hospital,
Harvard Medical School, from 1965 to 1966.
3 r. Plaintiff is on ss:t,, sided HOO after taking deductions .
4. Do you have any cash or checking or savings accounts? X-] Yes I] No
497
lf“Yes," state the total amount. $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
thing of value? I] Yes El No
lf "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. -
None.
1 declare under penalty of perjury that the above information is true and correct.
6.%;/ ci m a -t~s ,,
Jury 1, 2007 _ _ . A-r/D /§7,¢;§-T5-T."
Date Signature ofApplicant -5 7
NOTICE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating all assets. ln addition, 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.