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

Case 1 :07-cv—00342-SLR Document 1 Filed 05/30/2007 Page 1 of 2
I AO 240 {Rev. 10/03]
DELAWARESREIL 4[O5)
` UNITED STATES DISTRICT COURT
DISTRICT or DELAWARE 0 7 · 3 A 2
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Plaintiff APPLICATION TO PROCEED
, g , V. WITHOUT PREPAYMEN T OF
vfZ%»/%» .»Z»·/fza/tam 2%%/ FEES AND AFFIDAVIT
_ Defendant(s)
CASE NUMBER:
I, g2·»’¤'»f0’W if declare that I am the (check appropriate box)
° ° Petitioner/Plaintiff/Movant ° ° Other
·-
in the above-entitled proceeding; that in support of my request to proceed without {I ii i` `i‘° nge ···¤<
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings •EQ that { I_._ t ,¤_¤ . slisf
sought in the complaint/petition/motion. l in l
irlslt Elliot
In support of this application, I answer the following questions under penalty of perj S ___J_g_____=
U.S. `“ ”i ‘ ‘ we *·····ee - — *
1. Are you currently incarcerated? ° @ ° °No (If "No" go
If "YES" State the place of your incarce1·atioI1Jr»2?réJv¢;2.¤— &;zA-e¢;é,»-are / BD $(`0·"‘n·m
Inmate Identification Number (Required): /U'!}/7.y,Y
Are you employed at the institution? ./{Ji Do you receive any payment from the institution?
Attach a ledger sheet from the institution of your incarceration showing at least the gast six months'
transactions
2. Are you currently employed? ° °Yes ° @
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.
b. If the answer is "NO" state the date of your last employment, the amount of your take-home
salary or wages and pay period and the name and address of your last employer.
3. In the past I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment • • Yes ·
b. Rent payments, interest or dividends · • Yes ·
c. Pensions, annuities or life insurance payments · • Yes • • @
d. Disability or workers compensation payments · • Yes · •
e. Gifts or inheritances · · Yes · ·
ii Any other sources • • · • No
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—00342-SLR Document 1 Filed 05/30/2007 Page 2 of 2
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4. Do you have any cash or checking or savings accounts? · · Yes
lf "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
· · Ye ®
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. _Q_
I declare under penalty of perjury that the above information is true and correct.
DATE SIGNATURE OF A IEPLICANT.
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an afiidavit
stating all assets. In addition, a prisoner must attach a statement certiiled 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.

Case 1:07-cv-00342-SLR Document 1-2 Filed 05/30/2007 Page 1 of 1
DELA WARE CORRE CTI ONAL CENTER
SUPPORT SER VICES OFFICE
MEMORANDUM
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To.- (hgh sB1#.-‘®§gs\¤Q@;)
FROM· Stacy Shane, Support Services Secretary
RE: 6 Months Account Statement —-—~
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Attached are copies of your inm e account statement for the months of
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T he following indicates the average daily balances.
MONTH Ar/ERA on DAILY BALANCE
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Average daily balances/6 months:
Attachments
CC.- File ( MIM
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