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

Case 1 :07-cv-00081-SLB Document 1 Filed 02/13/2007 Page 1 of 2
T AO 2·1D(Rev. IDIOB)
DELAWARE Rev, 4.*05
i N UNITED STATES DISTRICT COURT
msrutcr or DELAWARE
Mi What J6 Maz in
Plaintiff APPLICATION TO PROCEED
(g LL DE).; Lftmeali pf It £`é,·g{{,) K $`OC,iqf S €LVl€?-ga WITHOUT PREPAYMENT OF
DZ ·°""'°‘l y { D OMQZI Hr- '?*°¢¤¤ ZW FEES AND AFFIDAVIT
Defendant(s) _:
` CASE NUMBER: O { "· 3 il
I, M I {qq L Z Maz { V" I declare thatl am the (check appropriate box)
M Petitioner/Plaintiff/hdovant El 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 thatl am unable to pay the costs of these proceedings and that I am entitled tothe relief
sought in the complaintfpetition/motion. I . I
In support of this application, I answer the following questions under penalty of perjury: FC =
l. Are you currently incarcerated? El Yes M No (If "NO" go to Question 2) ’ "
If "YES" state the place of your incarceration ~; `
. Inmate Identification Number (Required): , l _
Are you employed at the institution? A/0 Do you receive any payment from the institution? O
Attach a ledger sheet Qom the institution of your incarceration showing at least the past sbc months '
transactions
2. Are you currently employed? El Yes E{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. If the answer is "NO" state the date of your last employment, the amount of your take—home
sala?gor wages and pay period and the name and address of your last emplo er.
]`K¢ Mr 4 if Hazel; 30, Zoof My income J:. zoo? ${579.72
3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employment ¤ Yes M No
b. Rent payments, interest or dividends Ei Yes rtl No
c. Pensions, annuities or life insurance payments H Yes El No
d. Disability or workers compensation payments El Yes M No
e. Gifts or inheritances 7 , El Yes ld No
f. Any other sources § 0 ci or gécru Ll hi 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 expect you will continue to receive.

Case 1 :07-cv-00081-SLR Document 1 Filed O2/13/2007 Page 2 of 2 A
i AD 240 Revzrse.[R¤v. iD/0]] {
DELAWARE Rev. MD5! Li Q g B
vllea gms, ff [2*4- 75
7; {oclug gQ ma! a*si9.’*8 y
-4. Do you have any cash or checking or savings accounts? if Yes El No
lf "Yes" state the total amount $ i O Ll 2 · 9 [vi? / [ [/O
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
El Yes [Vivo .
· 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.
Nena
I declare under penalty of perjury that the above infomation is true and correct.
. . A < .
O2" O3'_O7 Mkl/(zhgfff djtgzfbl
DATE SIGNATURE OF APPLICANT I
P ( . 1
Mr %#{,/ ·;[”//J/Z/9
NOTE TO PRISONTER: - 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.