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

Q;. Gigg 1 zglgigps/-@`Q,Z80—JJF Document 1 Filed 12/20/2006 Page 1 of 2 uxwmc
l ,. AO 240 {Rev. I0/03)
Y? DELAWAREgRev, 4/05] Q\
` UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE 6
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Tin all illtsiti
riaiatarr APPLICATION TO PROCEED
V. ‘ WITHOUT PREPAYMENT OF
’Ivti; Gwnsal Gngngtsmimu FEES AND AFFIDAVIT
Defendant(s)
` CASE NUMBER:] ig- [gm
I, Tjmi Mmyl declare that I am the (check appropriate box)
.E`E Petitioner/Plaintiff/Movant El Other
in the above—entitled proceeding; that in support of my request to proceed witho
23 USC §l915, I declare that I am unable to pay the costs of these proceedin an ·r·· * s`·-= l T rel
sought in the complaint/petition/motion. ._ I p
g lla; as tina
i l
In support of this application, I answer the following questions under penalty o perj ‘ ·; __ —-ei
. E] .
l. Are you currently incarcerated? ~·’‘·· Yes No (If "No' go o ue • ‘‘I‘ ·s‘""‘ "‘"···‘
If "YES" state the place of your incarceration Qiii. in §i()§§g@·,g§ Wl. `
Inmate Identification Number (Required): “\%f§§j\
Areyau employed at the institution? NB Do you receive any payment from the institution? ND
Attach a ledger sheet from the institution of your incarceration showing at least the gast six months ’ I
transactions
2. Are you currently employed? El Yes *°·- No
a. If the answer is "YES" state the amount of your t k -home sa ry o a es _ f__r _ ,_ _ _
,
b. If the answer is "NO" state the date of your last employment, the amount of yo take-home n
salary or wages and {gay period and the name and addres of your last employeild(\il\.‘$hmtft\ Cwiqiu lil '~\`*llll.D
Q-isa tml \l¤t•r'1£,2.*iG\W· lm $1- ¤: 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 E No
b. Rent payments, interest or dividends K1 Yes P No
c. Pensions, annuities or life insurance payments E1 Yes ¤l No
d. Disability or workers compensation payments E1 Yes ¤¤ No
e. Gifts or inheritances El Yes No
f. Any other sources El Yes H 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.

i ’ ?é6UQFTtE&EHmenr 1 mii¥aiea..id272ii/2006 Page 2 of 2 ‘
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AO 240 Reverse(Rev. IOID3)
DELAWAR.E§Rev. 4Jo5[ `
4. Do you have any cash or checking or savings accounts? 13 Yes I No
· If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
D Yes r 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. i\\i iN\ ?a'L\0\lil1 ihttrlli) \mN€.\\ llitil ML
not rivet smkts wm. No my mimi-gsm wsu A wom ssmmus Amis yan ass sx ap. csc anon can to mn, uaouwiw A
Qur, an uuicmuo, sm vu emma miccunts Qin ws alt, an mus, no Aut, sttxg. vo·n!rc\ aiu ha wastes M *i\\1*®’iW‘ ·
_ \x\ Matty \nK¤hils i\ril\\ "l¥\L %\\¤¤0’k\ Qi? M linN\l`\\) ·. I
I declare under penalty of perjury that the above information is true and correct.
O l2 i\% OC Tj`§§ iktxigig
DATE SIGNATURE OF APPLICANT
NOTE TO PRISONER: · A Prisoner seeking to proceed without prepayment of fees shall submit an
affidavit stating all assets. Ineaddition, 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