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

Case 1 :07-cv-00125-JJF Document 30 Filed 12/07/2007 Page 1 of 2
I AO 240 (Rev, 10/0]]
i DELAWA]%.EtRev. 4/05 I
C UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
i fhci;,ii»ia0.»i;z E- 23/cig,
Q Plaintiff APPLICATION TO PROCEED
_ V, 1 _ I WITHOUT PREPAYMENT OF
\DCi\/1gi* FQCIO, Siriiujrl tYtHr`l'j¤’1 i ct/Q, FEES AND AFFIDAVIT
Defendant(s) MJ g ZL; {REQ _ (J
in CASE NUMBER: 0 I I iu 5
I, QQQKI; E = [Cl / declare that I am the (check appropriate box)
Mi Petitioner/Plaintit`f}Movant Ci Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
- 28 USC §l9I5, I declare that I am unable to pay the costs of these proceedin nd
` sought in th comp aint/petitio otion. tg lf? I ''`` ` _
_ In support of this application, I answer the fol tions under penalty pe ·~ Q? 2
l. Are you currently incarcerated? Yes ij No (If "N · " go _____ _ _ __vvl____=_____A
I oisisiiiiiigibiswiriril i
If "YES" state the place of your incarceration S V6) it i" I"` 77lP``l`‘‘`` "` ig ‘ `"l`' " ‘
Inmate Identification Number (Required): Qi
Are you employed at the institution? 0/ 0 Do you receive any payment from the institution? gi {
Attach a led er sheet om the institution 0 our incarcer `én/showin at least the ast six months ’
transactions
2. Are you currently employed? El Yes No
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. M //4 `
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. Af
3. In the past 12 twelve months have you received any money from any of the following sources?
i a. Business, profession or other self-employment D Yes li/{
_ b. Rent payments, interest or dividends C1 Yes gy
c. Pensions, annuities or life insurance payments El Yes No
d. Disability or workers compensation payments E1 Yes time
e. Gifts or inheritances E1 Yes Ei/N;
- ti Any other sources ` El Yes IE/Noi
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-00125-.l..lIé in Deeomenl so r Filed 12/O7/2007 Page 2 oi 2
I AO 2.40 Reverse (Rev. 10r'il3] V .
DELAWARE$Rev, 4leS] I -
4. you have any cash or checking or savings accounts? III Yes FH/NK
If 'lYes" state the total amount $ ( l ,.
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ,s..e ~V—e
K! Yes 5166 _
If "Yes" describe the property and state its value.
6 l W List persons who are dependent on you for support, state your relationship to each person and
indicate how much you contribute to their suppott, OR state NONE if applicable. ·
. UT c B i _ F e Bang it wise r
Cicitdii n` ·
I OZ — ·· Book/corr
I declare under penalty of perjury that the above infonnation is true and correct.
r.»r—~ sea?-— %%
DATE SIGNATURE OF APPLICANT ·
NOTE T0 PRISONER: ~ A Prisoner seeking to proceed without prepayment of fees shall submit an
afiidavit 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.