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

_ I Case 1:07-cv-00040—Gl\/IS Document 3 Filed 01/25/2007 Page 1 of Ci i I
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UNITED STATES DISTRICT COURT
’ DISTRICT OF DELAWARE
_ Plaintiff _ 1 APPLICATION TO PROCEED
~1 _1 V1 A VYITHOUT PREPAYMENT OF
‘\{?@~ggr( { § DS?. C" its hfgctgitijj FEES AND AFFIDAVIT
Defeudant(s) J i 1
cass NUMBER: O7C V (IO
I, & ) H declare that I am the (check appropriate box)
@ Petitioner/Plaintiff/Movant ° ° Other
in the above—entitled proceeding; that in support of my request to proceed without prepa _ ent~et?fees_--orpcostas. .|,
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and thiiliill am entitled tbiiliereltief
sought in the complaint/petition/motion. ` ‘ ``“‘
I 11, if A
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In support of this application, I answer the following questions under penalty of perjury: ly G
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1. Are you currently incarcerated? ® ° °No (If ‘lNo_" go to ‘r_`. 1. s_~.e @ ,1,; £,,,·,§r4
"YESQTZ state thepplace ofiyour incarceration (\\L“i‘•Q.[§ · _’i&\O°>€\\ \'i>*·{i`!0¥l
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Are you.e.1;nployed·at theiinstitution? I; `Do youlreceive any payrnentnfrom the institution? A
I Attach a ledger sheet Qom the institution of your incarceration showing at least the past six: months ’
1 transactions ·
2. Are you currently employed? ° °Yes ` in _
a. If the answer isi"YES" state the amount of your tal·:e—h'ome salary or wages and pay period a
and give the name and address of your employer. I - l . I `
b. Ifthe answer is "NO" state the date of your last employment, the amount of your take-home
E >_ _ ‘ 1 salary or wages andpay period and the name and address ofiyour last em loyer. ·
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3. In thepast 12 twelve months have you received any money from any ofthe following sources? _
i a. p , Business, professioncr other self-employment · l i· '· -Yes A n
· b. Rent payments, interest or dividends ,_ 1 _1 . . I -- A- •-t· Yes ·
A c_. 1 . .,Rension_s, annuities or-elifeiinsuiancéipaynnents“ - " *· · Yes _ p_ g _p p 1 _ y _
d. Disability or workers compensation payments 1111 1 ,_.. ..., -- •a-· Yes; ‘ ··1‘=‘ `7"i‘_ — _ .- 1 3 w ip_ _`
1 Q_ _ 1: ..Git`tseorlinl1eritances- { “ 1 -- - · · Yes `
i ff I _ IAIIY other SOIIICGS n V •_• 1Ye5_ - t _ .- if- •·"NQ_¢',i ‘
‘ Iftlielanswer to any ot` themabove is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.
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J Case 1 :07-cv-OOO40—Gl\/IS Document 3 Filed O1/25/2007 Page 2 of 3, "
I AO 245* Reverse {Rev. `lD[OB] V
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l 4. Do you have any cash or checking or savings accounts? • • Yes
l If "Yes" state the total amount $ Q ‘
5. Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
_ valuable property? ·
` • • YES .
_ 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.
P _ I- declare under penalty of perjury that the above information is true and correct. '
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. E A N
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Case 1:3O7; y. QQQ4O—G|\/IS Document 3 Filed O1/25/2007 Page 3 of 3
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