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

` · _ ·_ Agmglvlpiupse 1:07—cv—00282-GIVIS Document 1. Filed 05/22/2007 Page 1 of 2
f` ` DELAWAIG Erv. · ‘ . ` _ ' ‘ — - . V `
, ~ UNITED STATES DISTRICT COURT
r DISTRICT OF DELAWARE
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_ Plaintiff i APPLICATION T0 PRO CEED
_ V. , WITHOUT PREPAYMENT OF
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" CASE NUMBER:
I, @(Q (Xg; § {`1 Q; \ tp) §Q6°`\ declare that I am the (check appropriate box)
Petitioner/Plaintiff/Movant ° ° Other r_,r ,. . , _ ._ ArVrrr... i
in the ab ove-entitled proceeding; that in support of my request to proceed without pr a-• aym ¤ ' •"”‘“*’“ ‘ ”“i‘i ‘*‘i
28 USC §l9 l5,_ I declare that I am unable to pay the costs of these proceedings ¤Y that I am entitled to the relie ’
sought in the complaint/petitiori/motion. £ I. 2 2
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‘ In support of this application, I answer the following questions under penalty of perj ’· p d wwip p_p;p
1. Are you currently incarcerated? ° °No {If "No" go to Question 2)
_ If"YES" state the place of your incarceration l£l;& cl i \jl;§ LJUTFE €s€>¤" { F F? o Céliliticp
Inmate Identitication Number (Required): Ll i
Are you employed at the institution? M20 Do you receive any payment from the institution? A/JO i
i Attack a ledger sheerfgoni the insritunon ofvcur incarceration skowingat least rne oasr six: rnonths’
transactions -
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2. Are you currently employed? ° ° Yes L ° No) ·- _ -
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a I _
_ 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-hoine
salary or wages and pay period and the name and address of your last employer.
3. , In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-ernployment • • Yes
b. Rent payments, interest or dividends I ` · • Yes
c. Pensions, annuities or life insurance payments ' • Yes Q-TNo__
d. Disability or workers compensation payments • • Yes
e. Gifts or inheritances * • Yes {X j__·
fr Any other sources i · • Yes {ijm_;{lio> `
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—00282-tGl\/IS ` Document 1 . Filed 05/22/2007 Page 2 of 2 . I ._
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I 4. Do you have any cash or checking or savings. accounts? ‘· ' YES
IIf"Yes" state the total amount S @ ‘ `
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
_ valuable property? ‘
I _ It` "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 I
indicate how much you contribute to their support, OR-state NONE if applicable. p
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_ I declare under penalty of perjury that the above information is true and correct.
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I DATE ~ SIGNATURE OF APPLICANT .
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
· stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
officer showing all receipts, expenditures, and balances during thetast sirmonths in your institutional accounts.
II you have multiple accounts, perhaps because you have been in rnnltipie institutions, attach one certified
statement of each account. ‘,