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

Case 1 :06-cv-00068-JJF Document 33 Filed 08/06/2007 Page 1 of 2
AO 240 (Rev. 10/03)

UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
ALVIA LACY ·
Plaintiff APPLICATION TO PROCEED
NATIONAL R&LROAD PASSENGER WITHOUT PREPAYMENT OF
CCIREOEATION (mms AK) FEES AND AFFIDAVIT
Defendant(s) -
CASE NUMBER: 06-68-JJF
Alvia Lacy `
I, I declare that I am the (check appropriate box)
°X ° Petitioner/Plaintiff/Movant ° ° Other .
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §19l5, l declare that l am unable to pay the costs of these proceedings and that I am entitled to the relief
soughtin the complaint/petition/moti on.
ln support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? ° Yes °X °No (If "No" go to Question 2) (QE; 52
.E./I
· :2
lf "YES" state the place of your incarceration G` F'!
E
Inmate Identification Number (Required): Eg-2
... §C,<·-z
Are you employed at the institution? Do you receive any payment from the institution? FE ih
` ·····i
Attach a iedger sheet from the institution of your incarceration showing at least the past six rnonths’
transactions $5
2. Are you currently employed? ° x° Yes ° No it.
a. If the answer is "YES" state the amount of your take—home salary or wages and pay period a
and give the name and address of your employer. My fate Of pay is $2D ,19
per/hour, My employer: is Amtrak, 10- G St:1·eet:,N.W. 3W1 32 , `lwashinqlzon, DC 20002
. 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 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment - · Yes X- No y
b. Rent payments, interest or dividends · • Yes X- No
c. Pensions, annuities or life insurance payments · • Yes X- No
d. t Disability or workers compensation payments • • Yes X- No
e. Gifts or inheritances · · Yes X- No
f. Any other sources • • Yes X- 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.

Case 1 :06-cv-00068-JJF Document 33 Filed 08/06/2007 Page 2 of 2
AO 240 Reverse (Rav. 10/03)
DELAWARE [Rev. 4fG5
4. Do you have any cash or checking or savings accounts? ·}¢ Yes · ·No
lf "Yes" state the total amount 68- O0
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
. valuable property?
x- Yes • ·No
If "Yes" describe the property and state its value. -
My home is valued at; $120,000. I
My car is valued at $6,000.
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.
Veldez Christy my son
G C my Gisandaughteir `
I declare under penalty of perjury that the above infomation is true and correct.
Auger; 6, 2007
DATE SIGNATURE OF A LICANT
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 p
officer showing all receipts, expenditures, and balances du ring 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.