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

. . r Case 1:07-cv-00344—G|\/IS Document 1 Filed 05/29/2007 Page 1 of 3
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` UNITED STATES DISTRICT COURT p
DISTRICT OF DELAWARE l
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i riaiaae APPLICATION TO PROCEED
. V. WITHOUT PREPAYMENT OF
lAl}}¤‘m%@ ` Qetxgew I kpeémgnh FEES- AND AFFIDAVIT
Defendant(s) . __ .
A `I CASE NUMBER; O T 3 A A I
I, llziygktg { declare that I arn the (check appropriate box)
°V(· Petitioner/Plaintiff/Movant ° ° Other ___ __ _ _ __ ____@_.t, _ W, A
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inthe above—ent'itled proceeding; that in support of my request to proceed without pr pa •§——» —-·¤ ieesorec ‘ l
28 USC §lQ15, I declare thatl am unable to pay the costs of these proceedings an that arn entitled to the reli f “
sought in the complaint/petition/motion. 2 Q .
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‘ In support ot` this application, I answer the follow` g questions under penalty of pei] 1 glggpygigyp i _ p t l
l. Are you currently incarcerated? ° ° No (If "No" go to Question 2)
s If"YES" state the place of your incarceration E
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Inmate Identification Number (Required): 3 ‘
Are you employed at the instihition? QQ Do you receive any payment from the institution? _§Q_ l
I Attach c Federer sheer from the fnrritnaorr ofvorir incnrsern tion s}zo»y·t`r:·=r at legs; Ike ons! six rrzoritlrs '
B 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 employerr ·
b. It 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 n me and address of your last employer. Q¢E[g_v1/ggg Sig fg
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3. s In past 12 twelv months have you eceived any money from any o the following sources? _ `
a. _ Business, profession or other self-employment · • Yes No
- b. Rent payments, interest or dividends l ‘ · • Yes i\/No
c. Pensions, annuities or life insurance payments • • Yes •\/No
cl. Disability or workers compensation payments · • Yes •`v( No _
e. Gifts or inheritances • • Yes ·i?No'
f. Any other sources · • Yes · No `
It the answer to any of the above is "YES" describe each source of money and state the amount U
received AND what you expect you will continue to receive.

,_~ _` ’ , Case 1:07-cv-0034gl—Gl\/IS [gocumpnt 1 _ Filed 05/29/2007 Page 2 of 3
- ACME Reverse (Rev, `lD)'D3} . l =
DELAWAPTE [Rev. 4/ns: - I I
A 4. Do you have any cash or checking or savings accounts? • · Yes ·\,A~lo
If "Yes" state the total amount $ ’
- S. Do you own any real estate, stoclcs, bonds, securities, other financial instruments, automobiles or other
_ valuable property? ‘ p
· · Yes ·VlGo l
A g g 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 l
indicate how much you contribute to their support,. OR state NONE if applicable. J
p I declare under penalty of perjury that the above information is true and correct. l
- é DATE; · SIGNATURE DF APPLICANT - .
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
A stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
officer showing all receipts, expenditures, and balances during the last sixrnonths in your institutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account. D ·

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