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

Case 1:07-cv-00254-JJF Document 1 Filed 05/07/2007 Page 1 0f 2
(aw. 4191) UNITED STATES DISTRICT COURT
` - DISTRICT OF DELAWARE
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I rmnarr APPLICATION TO PROCEED
V. ‘ WITHOUT PREPAYMENT OF
n FEES AND AFFIDAVIT -
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Defendant(s) l . 1 -._ A 0 T 2 5 A
CASE NUMBER: - ..` C ~
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L OJ/XGV Q ` declare that I am jp jab ?`WYpi‘oj5`1‘iI1’&`i5C? /
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Petitioner/Plaintiff/lliovant _ Other · _ ·
l l I ‘·°"’*"`“'*T"'T~""‘·"`“*==“J==¤r¤r·e=ii
. _ U.S.
. in the above·entitled proceeding; that in support of my request to proceed Wlt}10
imder 28 USC §1915,_ I declare thatl am unable to pay the costs of these proceedings and · at am e {
relief sought in the complaint/petitionfmotion. RQ —${O“‘7 W) ‘
In support of this application, I answer-the following questions under penalty of perjury:
1. Are you currently incarcerated? . mis El No (lf "No" go to Question 2)
If "YES" state the place of your incarceration .
Are you employed at the institution? Do you receive any payment from the institution?
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2. Are you currently employed? U Yes Elm I
a. If the answer is "YES" state the amount of your takeéhome salary or wages and pay period and
give the name and address of your employer. .
b. If the answer is "NO" state the date of your last em‘ployment,··the amotmt of your take-home n
_ salary or wages and pay period and the name and address of your last employer. · ` p
3. In the past 12 twelvcmonths have you received any money fromany of the following sources? I
- Business, profession or.otl1er self-employment g = ‘-u- ¤* Yes` ¤JNo · l ·
b. Rent payments, interest or dividends EI Ya uf No
c. Pensions, annuities or life insurance payments D Yes ` El} No
· d. Disability or workers compensation payments y D Yes mf No _ I p
e. Gifts or inheritances ' A i ·i · D Yes I;/fNo .
f. Any othersources _ . D Yes No
‘ “ Y ` "-.l * i"."- "1 . ` i ‘._‘ "
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. A ·- ··=- ·

p Case 1 :07-cv-00254-JJF Document 1 Filed 05/07/2007 Page 2 0f 2 _
I 4. . Do you have any cash or checlcing or savings accounts? p ¤Yes @50
It "Yes" state the total amount S
5. Do you own any estate, stoclcs, bonds, securities, other linancial instruments, automobiles or other I
__ valuable property? C .
¤Yes Q/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.
I declare under penalty oi perjury that the above information is true and- correct. `
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DATE I SIGNATURE APPLICANT
` T 1 llyii CERTIFICATE"` ` 1 C
` (incarcerated applicants only)
I certify that the applicant named herein has the sum of S . A I- · on account his/her credit at (name
¤f insiiwticnl
I further certify that the applicanthas the followinp securities to hislher credit: 5 . . r
I further certify that during the past six months the applicant's average monthly balance was S .
and the average monthly deposits were S » I = . -
nm sxemruan or aurnomznn omcna
(NOTE THEREQUIREMENTINITEM1 FOR THEINZILATE TO OBTAINANDATTACHLEDGER SHEETS
OFACCOUNT TRANSACTIONS OVER THE PAST SIX MONTH PERIOD. LEDGER SHEETS ARE NOT
REQUIRED FOR CASES FILED PURSUANT T0 28: USC §2254) . - ,