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

Case 1 :07—cv—00344-GIVIS Document 11 Filed 10/26/2007 Page 1 of 2
I AG 240 {Rev. 10/O3)
DELAWARE Rev. 4/05
I UNITED STATES DISTRICT COURT
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DISTRICT OE DELAWARE gg 52*; NK
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Plaintiff APPLICATION TO PROEEQED y
V. WITHOUT PR.EPAYMEFiI*` @§
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i,lt;m-,¤gE,m §~3¤\,;, f§_;,$§( By gl FEES AND Ainnnaiafr ee
efendant(s) nl"
‘ CASENUMBER: \'·O"[.-uf-· 'LJ-ll-l Q/"{ 5
I, gm gt b` A l I lg l declare that I am the (check appropriate box)
EV Petitioner/Plaintiff/Movant E1 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 thatI am entitled to the relief
sought in the complaint/petition/motion. .
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? D Yes me (If "No" go to Question 2)
If "YES " state the place of your incarceration `
Inmate Identification Number (Required):
Areyou employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet Qorn the institution of your incarceration showing atleast the gast six rnonths'
transactions
2. Are you currently employed? El Yes @2
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.
D5. L. 5. qlist, - 1/0-i/q.w/»¢{m.»5it~A nv;
3. In the past l2 twe ve months have you received any money from any of the following sources?
a. Business, profession or other self-employment D Yes I3!/No
b. Rent payments, interest or dividends El Yes 13/ No
c. Pensions, annuities or life insurance payments U Yes K1/No
d. Disability or workers compensation payments El Yes EV No
e. Gifts or inheritances El Yes ISI/No
f, Any other sources |3|/ Yes El 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—00344-GIVIS Document 11 Filed 10/26/2007 Page 2 of 2
AO 240 Reverse (Rev. IU/U3)
DELAWARE Rev. _4./05)
4. Do you have any cash or checking or savings accounts? El Yes E14
lf "Yes" state the total amount $
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
El Yes K1/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.
l\l¤n<,
l declare under penalty of perj ury that the above information is true and correct.
tO/9~6£OZ gilmgg -
DAT SIGNATURE OF APPLICANT ·
NOTE TO PRISONER: - A Prisoner seeking to proceed without prepayment of fees shall submit an
affidavit stating aIl 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.