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

Case 1:07-cv-00015-JJF Document 1 Filed O1/O9/2007 Page 1 of 2
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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IA/mgm Q. t., Emma' ,J:··.
Plaintiff APPLICATION TO PROCEED
v. WITHOUT PREPAYMENT OF
Z hytggx Q FEES AND AFFIDAVIT
Defendant(s)
` CASE NUMBER: , O
, _ T ‘ 0 1 5
I, Z [ Q2 [ I EEQHQ [3,, ZE, declare that I am the (check appropriate box)
E Petitioner/Plaintiff/Movant El Other
in the above—entitled proceeding; that in support of my request to proceed without prepa _ fe i g _ __ gg
28 USC §l9I5, I declare that I am unable to pay the costs of these proceedings and t I am `'``'`i`ii
sought in the complaint/petition/motion. . --e--- - ..A.
init il Elilil i
In support of this application, I answer the following questions under penalty of perjur gi I
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I. Are you currently incarcerated'? E Yes El No (If "No" go to
-. I ' • S(‘lJ't ·
If "YES" state the place of your incarceration Q!6?d0dT? < Inf" . {ra _ alias!
Inmate Identification Number (Required): ?
Are you employed at the institution? Do you receive any payment from the institution? pg
Attach a ledger sheet Qorn the institution of your incarceration showing at least the gast six months ’
transactions
2. Are you currently employed? E Yes El No
a. If the answer is "YES" state the amount of your ta e—home salary or wages and pa period a
and give the name and address of your employer.}- 40 QH PIOUV; *944-· JSC hfdhfélgj
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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 ofthe following sources?
a. Business, profession or other self-employment El Yes III No
b. Rent payments, interest or dividends El Yes El No
c. Pensions, armuities or life insurance payments U Yes III No
d. Disability or workers compensation payments El Yes E1 No
e. Gifts or inheritances El Yes E1 No
f. Any other sources D/Yes El No
If the answer to any of the above is "YES" describe each source of money and state the amount
rece; w a you expec you w con mue o receive S/$+6;,.} #{00 gw g/gy-/V
'dAND ht t ill t` t `. ‘ -
60 lays.

Case 1 :07-cv-00015-JJF Document 1 Filed O1/O9/2007 Page 2 cf 2
AO 240 Reverse (Rev. 10/03)
DELAWARE Rev, fli'05)
4. D0 y0u have any cash 0r checking cr savings acccunts'? IB/Yes EI N0
lf "Yes" state the tctal amcunt $ { { SQ Vfiqgg (2CCOf¢(H‘|f')
5. D0 you own any real estate, stccks, bcnds, securities, cther financial instruments, automobiles 0r other
valuable property?
IV/Yes El No .
If "Yes" describe the property and state its value.
010 5)+0Ck; l/62 {ME (62.9 Orc O7A5m6') :
6. List the persons who are dependent 0n you for support, state ycur relaticnship t0 each person and
indicate how much ycu contribute to their support, OR state NONE if applicable. ·
I declare under penalty 0f perjury that the ab0ve infcrmaticn is true and correct.
i DA i E g SIGTNAIIURE OF APPLICé@T ‘
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.

Case 1:07-cv—OOO15-JJF Document 1-2 Filed O1/O9/2007 Page 1 of 1
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