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

_ ;, Case 1 :07-cv-00101-GIVIS Document 1 Filed 02/21 /2007 Page 1 of 2 *
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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_ Piataurr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
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Det`endant(s) .
`I CA ENUMBER:
_ D S E or-101
I, T declare that I am the (check appropriate box)
° ° Petitione1{Plaintif_@/Movant ° ° Other A
__ inthe above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l915, Ideclare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petitionfmotion.
‘ In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? ° I ° °No {If "No" go to Question 2)
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_ If "YES" state the place of your incarceration QQD R www
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Inmate Identilication Number (Required): Z gf;
A.re you employed at the institution? Do you receive any payment from the institution'? &O I
l Attach a ledger sheer fiom the institution of your incarceration showing at least the past sb: mon:/is ’
transactions ·
2. Are you currently employed? ° ° 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.
b. Ifthe 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.
3. t In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employrnent • • Yes • •®
b. Rent payments, interest or dividends i • • Yes • ·@
c. Pensions, annuities or life insurance payments • · Yes · ·
d. Disability or workers compensation payments • · Yes · · @53 F
e. Gifts or inheritances • · Yes · · @
f. Any other sources * • Yes • •® I
If the answer to any ofthe 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-00101-GIVIS Document 1 Filed 02/21 /2007 Page 2 of 2 L
V V AO 240 Reverse (Rev. 10/03) .
DELAWAREt§ev. QUE] - .
V 4. Do you have any cash or checking or savings accounts? · · Yes • ®
If "Yes" state the total amount $ ’
S. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
_ valuable property? ‘
· • Yes · ®
I If "Yes" describe the property and state its value.
6. List the persons who are dependent on you for support, state • . elationship to each person and
indicate how much you contribute to their support, OR stat f applicable.
_ I declare under penalty of perjury that the above information is true and correct.
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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 certitied by the appropriate institutional
officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
H you have multiple accounts, perhaps because you have been in multiple institutions, attach one certitied
statement of each account.