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

Case 1 :07-cv—OOO59-SLR I Document 1 Filed O1/29/2007 Page 1 of 2 ‘
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Myles A. Hart
_ riarnirr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
Correctional Medical Services FEES AND AFFIDAVIT
Defendant(s) .
CASE NUMBER: "` O T " "‘" 5 Q —~·-
I, ___.. declare that I am a e gg it g __ z
° E5 Petitioner/Plaintiff/Movant ° ° Other F., ,_ , ___1 _ ,_ ____P, . A,_, __,
inthe above-entitled proceeding; that in support of my request to proceed without pr pa nt o'iAHs&rq@B*r11d
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings that! am n 1 i o e reli f
sought in the complaindpetitiorrjmotion. E ___A,p_ _ W __ __ __ _._1, . ;,_ _ _____ i
l U.S. DlS'iRiCl“ CUUH G
,,. .,.. N.
In support of this application, I answer the following questions under penalty of perjury: glu
1. Are you currently incarcerated? °’“ Yes ° °No - (If "No" go to Question 2)
If "YESA" state the place of your incarceration H Ow of d R · Y 0 U tl g C G Y Y Q C ii I 0 U at
Inmate Identiiication Number (Required): QUQQQ 2 ill {
p Are you employed at theinstitution? NO Do you receive any payment from the ins titution? N0 l
I Attach a ledger sheet Qom the institution of your incarceration snowing at least the gas! six rnoni‘hs’
transactions A
2. Are you currently employed? ° ' Yes l x 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
salary or wages and pay period and the name and address of your last employer.
3. In the past I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other seif—employrnent • · Yes -1: No
b. Rent payments, interest or dividends · • Yes •Hl’No
c. Pensions, annuities or life insurance payments • · Yes ·x No
d. Disability or workers compensation payments • · Yes ·>* No
e. Gifts or inheritances •x Yes · · No
f. Any other sources • • 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. F ami I y Sen d s mo n e y
orders

Case 1 :07-cv—OOO59-SLR Document 1 Filed O1/29/2007 Page 2 of 2 in
AO'2·1.G Reverse (Rev. l.U/O3)
DELAWARE Env. i.:'U5i ` ,
l 4. Do you have any cash or checking or savings accounts? 3, • Yes • •No
If "Yes" state the total amount S O · OO ‘
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘
_ · • Yes ·,; No
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.
1 . C: H . 2 . M H ; 3 . Ca H
it . M H 3
All around financial support
I declare under penalty of perjury that the above information is true and correct.
.,, l ` "*—
i i 1 i l 0 '3
` DATE - SIGNATURE OP APPL ANT
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, andbalances 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.