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

_` ` _ Case 1:_O7-cv-OOO40—Gl\/IS Document 6 Filed 01/31/2007 Page 1 of 2 ‘ I
. , - AO240i[Rev.1UjD3) . _ - V . ·
` i DELAWARE Bev. V ‘ _ ` . ‘ ‘ . ~ , . V
UNITED DISTRICT COURT -
_ _ _ _- _ __ _ P E - . -_ y __=a_‘ __ __ -
time m earn .
_ piatiiirr — I APPLICATION TO PROCEED ‘ y _ y
Ny U (lm egg mg; V. , H ,_ VVITHOUT PREPAYIYIENT OF y n
p J a _ r D in Sn ·—·—. esa-am and FEES Anntnrrrnavrr p
mi`. Kttpthttiii "otQtt`tiitti?nc;._; Defendant(s) _ _ . p
P ·t cassuumsaa; .07-L-l0 ¤l'>~=¤l~d¤ *
n l ` I, i Q -.l\Bl"4l/\ Ut `gbmx declare that I the (check appropriate box)
¢ Petitioner/Plaintiftfb/iovant ' °‘ Other n l
~ ~ - inthe above-entitled proceeding; that in support of my request to proceed Without pr ‘ I
28`USC-§l9l_5, I declare;--that I am unabfeetotpay inseam oftheseproceedings an that -: z- v r as , _ f _ ge ____ y
sought in the complaintfpetitionfmotion. ` , y g A A i
- _ . tlAN.3'l EUG? .
‘ In support of this application, I answer the fo-llgwirigllguestions under penalty of pe Z ¤ ar=---- { Tm U _
- I`.? Are you currently incarcerated? C ‘ Yes. • °No (If "No" go ·;·=
t t Ahhl ] -3 gk tg Y ri a itil Bp 9 22. E .. . Y i
_ _ ·1t"'YES" state the place of your incarceration ll · G1"` . yi t:i€\"?x G- ·i ll.Qt*“> "·;,‘?t`?`l wit
. a;,,y;€~» ; ‘ ` _ I
Inmate Identification Number (Required): os &O I O c y _ . i
· Are you employed at the institution? N D Do you receive any payment from the institution? M _ Y P
' I · l Attach a ledger sheet [fom the institution of your incarceration showing at ieastjtne past sb: months ' Q
- _ transactions · V » _ - _ _ .
2. Are you currently employed? ° °Yes ° _ · l ` . ` _ .
Y a. Ifthe answer is 7'YES" state the amount of your take-home salary or wages and pay period a I =
· and give the name and address of your employer. _ 1 (
b. · If the answer is "NQ" state the date of your last employment, the amount of your take-home _ ` - Y
_ _ salary orwages and pay period and the name and address of your last employer. 5
l 3. , the past 12 twelve months have you received any money from any ofthe iollowing sources? _‘ I ` _ ` Y
I a. Busincss,profession or other self—employment • • Yes ( · •“l;lo ( an " Y P r
b. Rent payments, interest or dividends Y • • Yes E ` . j _ l
e.. . . Pensions, annuities or life insurance payments · • Yes - I . j _
dr-- 3 - Disability orworkers compensation payments · • Yes _ ` i l y
er Gifts or inheritances • · Yes y · E [
f. Any other sources • • Yes ` l Z
l _ · ¤T..,,...-.(—.-v=*" l H _ rl I
‘ It 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. · I - . y
I c in _.___ v _ _.__

n Case 1:07-cv-00040—Gl\/IS _ Document 6 Filed 01/31/2007 Page 2 of 2 r
- _ AO140 Reverse (Rev. ll}/D3} U - l U I _ r_ V {_ _
_ DEi.AWABEt§ev, QUE! ~ V . V .` »
4. Do you have any cash or checking or savings accounts? • • Yes •i_j__l}lp;_ l
l if "Yes" state the total amount $ l l __sn l
5. Do you own any real est‘ate, stocks, bonds, securities, other financial instruments, automobiles or other ` ···‘ · -— -. l ` l ,
__ valuable property? ‘ _. · _ l
‘ ··Yes t••Nol _ _.p
0 p If "Yes" describe the property and state its value. V _
. i
_List the persons who are dependent on you for support, state your relationship to each person and i
indicate how much you contribute to their support, OR state NONE if applicable. r in
e a i it l
_ · declare under penalty of perjury that the above information is true and correct.- V _ _
· l ’ - ' . Q4 ,\ [ yr I - l .
M., ___,_/ ,. M ' Z -‘··i ·'· ·’ ‘i · l
_ l Elle 0*1 gk lla ssr. 3MlJ tliéftj s l
DATE _ · SIGNATURE OF APPLICANT _ _. pp _ I
NGTE T0 PRISONER; A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit- l v
· stating all assets. In addition, a prisoner must attach a statement certitied by the appropriate institutional _ p ·
officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. i `
lf you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified, ,.. is 2
. ` statement of each account. ‘ · - "
. · i |
» · -l