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

Case 1 :07-cv-00070-SLR Document 1 Filed O2/07/2007 Page 1 of 4
240 {DELAWARE REV Tn'00) l
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Plaintiff APPLICATION TO PROCEED
WITHOUT PREPAYMENT OF E
V. FEES AND AFFIDAVIT
Defend i · .· _ CASE NUMBER: ‘ ‘· 1
/ / S "i"' O T "" 7 O "" ‘*‘
1 f g Ji declare that I am the (check appropriate box)
A _, e ·n1 e »erfPlaintii`f/Mov t K] Ot r in the above-entitled proceeding; that in support of my
request to proceed without prepayment of fees or costs under 28 USC § 1915, I declare that I am
unableto pay the costs of these proceedings and that I am entitled to the relief sought in the .
complaint/petition/motion. t
In support of this application, I answer the following questions under penalty of perjury: l
1. Are you currently incarcerated? J, —~‘’ -4Yes El No (If "No" go to Question 2) - I 1
‘ fi B I Z
· If"YES" state the place of your incarceration/5 VI/Q 1 1 1 1 1 1 . 1 1. 1 I
Are you employed at the institution? El Yes!E No ‘ " ‘ I ·c ·· - ~ -- 1 -
F if ..
Do you receive any payment Eoin the institution? EI Yes No tig " 7 {E t
Have the institution ill out the certi zcate » ortion 0 this 0 davit and attach a I er H 't`' rZ. ¤ ·
institution s 0 our incarceration showin at least the ast SLX'months'transo .... . 7 {__ ____
sheets are not required for cases jled gursuant to 28: USC §2254. B D S {ann C9;
2. Are you currently employed? EI Yes w No
a. Ifthe answer is "YES" state the amount of your take-home salary or wages and pay period and
give the name and address of your employer. _
be 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. A
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 Cl Yes No
b. Rent payments, interest or dividends K1 Yes [B? No I
c. Pensions, annuities or life insurance payments EI Yes [El No
d. Disability or workers compensation payments EI Yes W No
e. Gifts or inheritances EI Yes No
f. Any other sources I] Yes No
If the answer to any ofthe above is "YES" describe each source of money and state the amotmt
received AND what you expect you will continue to receive.

Case 1 :07-cv-00070-SLR Document 1 Filed O2/07/2007 Page 2 of 4
ft. ia Do you have any cash or checking or savings accounts? I] Yes Mme
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial ins E ents, automobiles or
other valuable property'? I] Yes e `
If "Yes" describe the property and state its value. .
. __p\ {
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.
I declare der penalty ofpeijury that the above infomation is ¤»· e and err t. ~‘; t
Dat€ Signature of Applic t . ‘ ‘
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.. . Case 1:07-cv-00070-SLR Document 1 Filed O2/07/2007 Page 3 of 4
(R.av.4rsn UNITED STATES DISTRICT COURT
` " DISTRICT OF DELAWARE I I
APPLICATION TO PROCEED
S . at 1 wrrttour PREPAYMENT or
V J FEES AND AFFIDAVIT
I g Defendant(s) g _ _ W -
;&7%éy %ASE NUMBER;
L declaret ·· box)
Petitioner/Plaintiff/Movant Other I . i—¤ FEB - § ZUUI ip ·
. in the above-entitled proceeding; that in support of my request to ·. ?* •» " p i et fees l
or costs under 28 USC §l9l5, I declare that I am unable to pay •¢ _.t2 _` •- .. .· and ’
that I am entitled to the relief sought in the complaint/petitionfmotion. _ I
I In support ofthis application, I answer the following questions under penalty of perjury; .
1. Are you currently incarcerated? No U (If "No" go to Question 2)
If"Yes" state the place of your incarcerationyéfi Q Z 0 Z I (
Me you employed at the institution? " Do you receive any payment from the institution? Nb
Have the institution fill out the certificate portion of this affidavit and attach a ledger sheet from the
institutionlsl of vour incarceration showing at least the past SlX months’ transactions. The ledger]
sheet is not required for cases tiled pursuant to 23: USC §2254. {
_A 2. Are you currently employed? — Yes
a. If the answer is l"Yes*’ state the amount of your take—horne salary or wages and pay period and
give the name and address of your employer. ` Q
b. If the U-answer is “NO"· state the date of your last ernployrnenti the amount of your take-home;
salary or wages and pay period and the name and address of your last employer. _
3. In the past twelve months have you received any money from any of the followin sources? I ,
. r_ l
a. Business, profession or other self—employrnentp Yes No
b. Rent payrnents,;interest or dividends Yes · l_ No I pl
c. Pensions, annuities or life insurance payments Yes · ” No U
d. Disabilitylor workers compensation payments ` ‘ Yes No · A _ `_ I`!
_ e. _Gitts or inheritances Yes _ No
ii Any other sources Yes \No
lfthe answer to any ofthe above is ·‘fYES" describe each source of-money and state the
amount received AND what you expect you will continue to receive. I

"““‘“*“’_“—'/<.E§ei1 :07¥oi) l}l'm Doeuinent 1- Filed 02/07/2007· Page 4 of 4
4. Do you have a` orchecking or savings aeeoums?i _. . __ ._ O .‘ Yes @ _ - i i A
Itl"Yes" state the total amount $ ... _........ ._ --..,.. . i
5. Do youiownaiiaxry-*Areal estate, stockspbonds`, securities, other financial ins ·· · automobiles or I
` other valuable property? ’ ‘ . ‘ Yes W
L ' I _ Ifl‘Yes’i descrihe-Itlieiiproperty state its value. n A ‘
i 4.·o ‘i l
6. Listthe 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 I
/K/OA//Q r ,
_ ‘ I O LI declare under penalty of perjury that the is true and correct. p
) l ‘ 1.4 l ]4J .4I.¤.11 ·
DATE V SIGNATURE OF · ' LICANT