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

Case 1:06-cv-00057-JJF Document 11 Filed O3/O3/2006 'AB§géJTUt;l“‘3i“`
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_ q¤.~.4m> a UNITED STATES DISTRICT COURT ·
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- A i _ 1-·e riainen ·-’e 5 · = y · i · APPLICATION TO PROCEED
Q.; c.\e\-`i·=tr\¤..—;Qm.¤. V. _. — WITHOUT PREPAYMENT OF
_Psc.\ BK Q Sm · ,_ gv ircmi FEES AND AFFIDAVIT i
. · -. » -h;\— - ss TS. ‘i?e·lAlere:X¤ ¤·?`·€?’"E“~"§ €t"P1~?°* . .
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p Defendant(s) i i
CASE NUMBER: O(¤”
I, E gig ®\®ii\€. Q gg · - _ declare that I am the (check appropriate box)
E Petitioner/Plaintiff/Movant ‘ El ‘Other”·""‘-* AA" `· · - `A“’ ‘*’ * B ***·*i‘
in the above·entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC §1915, I that I am unable to pay the costs of these proceedings and that I am entitled to the
relief sought in the complaintfpetitionfmotionzl _ p 3 ZW __ g gw { g _ _ I T _ p
In support of this application,—I answer the following questions under penalty of perjury:
1. · Are you currently incarcerated? Yes D No (If "No" go to Question 2) A _
If "Y”ES" state the place of your incarceration EF gi L ` `Qgn Qggg;—i;ig;i—.KL%i¤ &$it>·o
Are you employed at the institution? Q;-2 Do you receive any payment from the institution? Mi;.
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nu r'! ‘!. rf!. AHVIIIA fl Hi fi ‘ ‘!'=: ra ‘
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2. Are you currently employed? A A ¤AAYes E NoAAA A A A
a. AA A A If the answer is "YES" state the amountof your take-home salary wages payperiod and
give the name and address ofyour employer. _ g _ ‘ ‘ _ g. . . . ‘ i ,
b. If the answer is "NO"- statAeAAthe'dateAof your last employment.AtheAamountA talteehome A
p salary or wages and pay period and the name and address of your last employe . A A
`— A ~· .53, ,; ,=L _;. _ A .e A ‘., ‘~ ‘ - — V` " AA _' LU y
3. In the past 12 twelve months have you received any money from any of the following so ·: fg, gg
A . [A · ` CU f ~ E
a. Business, profession or other self-employment D Yes No Ai ¤’> q
‘ b. Rent payments, interest or dividends Cl Yes bg No .. A D LQ}
1 c. Pensions, annuities or life insurance payments C1 Yes we ] LI.) § 5§
d. Disability or workers compensation payments A ci Yes Fm o A . E fg
c. or inheritance: _ K Yes \@No - D
_ i f. other sources ·_. .· , _ 9 _‘¤;Yes_ \_sNg».j __; .. .
i If the anim} toany at the snow) is ·A·Y1:s·· describe each source of moneyand state the amount A - A
I received AAT) what youexpect you will continue to receive. . . J . . . .
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Case 1 :06-cv-00057-JJF Document 11 Filed O3/O3/2006 Page 2 0f 3
4. Do you have any cash or checking or savings accounts? ¤Yes ENG
If "Yes" state the total amount $_____________ _
· /
S. Do you own any real estate., stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? X " `i E T i ’ -
_ _ ¤Yes \No
If "Yes" describe the property and state its value. I n i i,_*__‘i I · A
6. List the persons who are dependent on you for support, state elationship to each person and
indicate how much you contribute to their support, OR sta`te applicable.
I declare under penalty of perjury that the above infonnation is true and correct.
/r¤?i>`Oé ‘ Cgfmwlne ipcnxwu DATE l . . . SIGNATURE OF APPLICANT
- CERTIFICATE `
(Incarcerated applicants only)
I certify that the applicant named herein has the sum of S ·Q~O on account his/her credit at (name
ofinstitutioni I 26/IOQQS T. Q Efltégzs wQ[[@1§ l `Q 1 lf! ‘744.¢rZj] L p . _
I further certify that the applicant has the following secuuiiins to his/her credit:
» T I (Imc, t .
I further certify that during the past six months the appiicant's average monthly balance was S [5
I _" andthe averaggiraouthly deposits were S__Q 6· 66 · » .
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:. . Dat SIGNATURE OF AUTHORIZED OFFICER
(NOTE THE UIREMENT IN ITEM I FOR THE INMA TE TO OBTAJNANDA TTACH LEDGER SHEETS
OF A CCOUNT TRANSA CTIONS OVER THE PAS-T SDI MONTH PERIOD. LEDGER SHEETS ARE NOT
REQUIRED FOR CASES FILED PURSUAN"I` TO 28:USC‘§2254) ‘ ~

Ca e 1 :O6—cv-OOO57—JJF Document 11 Filed O3/O3/2006 Page 3 0f 3
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