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

Case 1 :07-cv-00018-SLR Document 1 Filed 01/10/2007 Page 1 of 2
(pu. we UNI'I'ED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
I V. WITHOUT PREPAYMENT OF
[ _ A / . FEESANDAFFIDAVIT .
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Defendant(s) _, O -§
CASE NUMBER: T `"' O 8 I
I, 2 Q gv//A `7; 5 Q #4/,4 { declare that I am the (check appropriate box)
Q/ Petitioner/Plaintiff/Movant n U Other t _
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC §191S, I declare thatl am unableto pay the costs of thue proceedings and that I am entitled to the
relief sought in the complaintlpetitionlmotion. J 45 M_
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In support of this application, I answer the f questions under penalty of perjury: Q3; Z
1. Are you currently incarcerated? Yes D No (If "No" go to Question Z)5:" I
J
If "YES" state the place of your incarceration gw We #/ (2 " **1 H § 6* M ·’
Are you employed at the institution? [ij QP Do you receive any payment from the institutioi? iii A
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2. Are you currently employed? I EI Yes 0
I a. If the 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. I
1 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.
/7%,5% p/ 2;-96 ‘/
3. In the past 12 twelve months have you received any money from any of the foIl urees?
a. Business, profession or other self-employment D Yes
b. Rent payments, interest or dividends ¤ Yes ¤)lo
c. Pensions, annuities or life insurance payments D Yes /E/No
d. Disability or workers compensation payments D Yes Je
e. Gifts or inheritances D Yes No
f. Any other sources . ¤ Yes 13%
If the answer to any of the above is "YES" describe each source of money and state the amount
rcceivedAND what you expect you will continue ·to receive.

Case 1 :07-cv-00018-SLR Document 1 Filed 01/10/2007 Page 2 of 2
4. Do you have any cash or checking or savings accounts? ¤Yes %
If "Yes" state the total amount S 6
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, autom iles or other
valuable property?
, ¤Yes III o
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. `
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I declare under penalty of perjury that the above information is true and correct.
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D SIGNATURE OF LICANT
· CERTIFICATE `.
(Incarcerated applicants only) __
· I certify that the applicant named herein has the sum of S on account his/her credit at (name
0flI1StllC|.ltl0ll) /66*-*4 F cv. H 9 r' rré/7 / if -
I further certify that the applicant has the follo g securiti to hisfher credit: " `
é G CZ O fv;1 k ,
I further certify that during the past six months the applicant's average monthly balance was $61 3 · 0 J
and th average monthly deposits were fg n .
V J
te SIGNATURE OF ORIZEI) OFFICER
GVOIE THE REQ£ZIRE1\{E1\'I'I1V1IEl{ 1 FOR THE INMAIE TO OBTAIN ANDATTACH LEDGER SHEETS
OF ACCOUNT TRANSACTIONS OVER IHEPASTSIX MONTH PERIOD. LEDGER SHEEISARE NOT
REQUIRED FOR CASES FILED PURSUANT TO 28: USC §2254)