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

Case 1:07-cv-00234-SLF{__ Document 1 Filed O4/30/2007 Page 1 of 2 P MC- L
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UNITED STATES DISTRICT COURT .. .,__
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DISTRICT OF DELAWARE & ++·~ _.~’
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PHL}!. Cb t.LL`·lVl ljK Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
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l lll. Bokltxltq ·_©l'*’\l°i‘~N{ FEES AND AFFIDAVIT
Defendant(s) __ _ .
CASE NUMBER: F O { 2 3 A
F"} _ ’ \ -’* i ' ` r,
I, _ i U l;_ _ lr- U L L- k N\ declare thatl am the (check appropriate box)
E Petitioner/Plaintiff/Movant El Other
in the above—entit.led proceeding; that in support of my request to proceed without g . vment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings
sought in the complaint/petition/motion. 5 ~i·· ·—=· ··-·—-J-—-»e~»-·--1.,
In support of this application, I answer the following questions under penalty of perjury: I l I
l . Are you currently incarcerated? Cl Yes g No (lf "No" go to I
If "YES" state the place of your incarceration _ ` _ _
Inmate Identiiication Number (Required); _ __ _
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet Qom the institution ofyour incarceration showing at least the past silt months ’
transactions
2. Are you currently employed? ij Yes E No
a. If the answer is "YES" state the amount of your tal 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 ofyour last employer. ..12'f&Z‘E£&‘. -- -
_ F\**’*=>¤~ rc I rw it mic- vt. BLt=~c+ 3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self—employment El Yes El No
b. Rent payments, interest or dividends El Yes BJ No
c. 1* Eggsions, annuities or life insurance payments H Yes No
d. Disability or workers compensation payments D Yes H No
e. Gifts or inheritances C1 Yes Ek No
f. Any other sources D 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 ex ect you will continue to receive. _ __
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Case 1:07-cv-00234-SLR Document 1 Filed O4/30/2007 Page 2 of 2
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_ PENIS/OMS A/V\cuNT RECEIVE? : LlNl
FILTMRE /\N\0um*: LlNl 4. D0 you have any cash or checking or savings accounts? ISI Yes U No
If "Yes" state the total amount S5 2- · Yi; (CASH) CHEC K I NG l U NKNGWNI.
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
D Yes Bf No
If "Yes" describe the property and state its value.
6. List the persons who are dependent on you fgrsuppggt, state your relationship to each person and
indicate how much you contribute to their support, OR state NONE if applicable.
Name, NOT AT THU Tl/WE .,
MY SITUATION HAS RFLENI L7 C HANGED .

I declare under penalty of perjury that the above information is true and correct.
A Mom DAY
zz Amit 2007 YCMZ Caaééem IDRO SE
DATE SIGNATURE OF APPLICANT
410 N/NTH VE, NE /\F’7Z¤i¥ 2+1 SE/lT1’LE U/A 3·H5"8511
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 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. g
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