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

Case 1 :07-cv-00081-SLR Document 8 Filed 11/O9/2007 Page 1 of 4
AO 240 (Rev. IO/OJ)
DELAWAR.E(Rev. 4/OS
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
; `‘‘` . Ni ii}- ZT i ii
Plaiiiiiff APPLICATION TO PROCEED
v. WITHOUT PREPAYMENT OF
. FEES AND AFFIDAVIT
Defendant(s) ,___ .1. - . -]
CASE NUMBER; Y -— b' [ -~ S L lx
lhli li si. [ .' "l‘-., I-
l, _ Qi ' i ( “i r"; Q · *` iii _ _ declare that I am the (check appropriate box)
[H Petitioner/Plaintiff/Movant ij Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l 5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury;
’ !
l. Are you currently incarcerated? El Yes No (If "No" go to Question 2) g egg
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If "YES" state the place of your incarceration. V 2 ESI
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Inmate Identification Number (Required): STB};
32 eee
Are you employed at the institution? Do you receive any payment from the institutioigz,
Q, S2?
Attach a ledger sheet Qtom the institution ot your incarceration showing at least the past st!¤nor%’ I
transactions A &
2. Are you currently employed? D Yes MNo `
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 tal 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 ofthe following sources?
a. Business, profession or other self-employment D Yes af No
b. Rent payments, interest or dividends Q Yes iff No
c. Pensions, annuities or life insurance payments liz'} Yes D! No
d. Disability or workers compensation payments E1 Yes IU No
e. Gifts or inheritances E1 Yes Ulf No
f. Any other sources D Yes No
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. p jQ` ti é 5 ‘·.»` ‘·‘”‘ u, a ` ; .

Case 1:07-cv-00081-SLR Document 8 Filed 11/O9/2007 Page 2 of 4
AO 240 Reverse (Rev. IG/O3)
netarvimerna. —1ll52
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4. D0 you have any cash or checking or savings accounts? ul Yes E No
lf "Yes" state the total amount SB I--ti
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
El Yes El1·"'No
lf "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.
L-, {gl
I declare under penalty of perjury that the above information is true and correct.
i .! if i, ji L. ,·“ _ lr l t l, ·t L [ r. fx _| ·' ,g ,‘ t 1
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 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.

_ _ _ £1ase21:O7-cv-00081-SLR _ Document .8 Filed 11/OQLZDDJ Rage 3 of 4 2% _
My total income for last 12 month have varied from $653.78 to $679.78 (see copies of the
checks for this year below and for last year next page. Next year my Social Security will grow on
2%, the pension will be in the same size up to the end of my live.
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