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

Case 1 :O6—cv—OOO38-GI\/IS Document 1 Filed 01/20/2006 Page 1 ot 2
AO 240 (Rev. lt]_/03)
DEL.-\I\'ARE (Rev. 4/05)
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE g H 6 _ 0 3 8
U
S TEP/YEA! R — NZM/M
piamurr APPLICATION TO PROCEED
V. WITHOUT PREPAYNIENT OF
6 Enum /2 - www FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER:
I, <5`7ETPf/Si/if .2 - WZNM declare that I am the (check appropriate box)
°""° Petitioner/Plaintiff/Movant ° ° Other
in the above—entitled proceeding; that in support of my request to proceed without ]irepaymeni;of ieeiaor gostiiiinder
28 USC §19l5, I declare that I am unable to pay the costs of these proceedings aiid tha?Wi1HieHtEl'e`Ei"€(:Ttlie"r"elir§:f
sought in the complaint/petition/motion. y Q i
g JAN Zo 20%
i s 2 E
In support of this application, I answer the following questions under penalty of perjury: ir rt —la-E--gg;:e;i1e;;1;?·;;=g-··=——i
‘ ii1¤:>,ij§P?Z§'£iéQi‘¢‘*? Ps;
1. Are you currently incarcerated'? °’“"°@ ° °No (If "No" goito-Question2‘)i f:Z..=fli-I is "?..~--.~.-.~-~--:i
If "YES" state the place of your incarceration D Ei H td A QE CGR Rigt Txgzifni C'GM‘/Zgjij
Inmate Identification Number (Required): f 7 7`YS 7
Are you employed at the institution'? NO Do you receive any payment from the institution? No
Attach a ledger sheet from the institution of your incarceration showing at [east the gast six months’
transactions
2. Are you currently employed? ° °Yes °"`?_~I£»
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.
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.
i 3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other se1f—employrnent • • Yes ··· No
b. Rent payments, interest or dividends - • Yes •·· No
c. Pensions, annuities or life insurance payments · · Yes •-·· No
d. Disability or workers compensation payments · · Yes ·¤ No
e. Gifts or inheritances • · Yes ·-··· No
f. Any other sources • · Yes ··-·· 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—00038-GI\/IS Document 1 Filed 01/20/2006 Page 2 of 2
AO 240 Reverse (Rev. 10/M)
DELAWARE (Rev. 4/D5
4. D0 you have any cash or checking or savings accounts? • • Yes ····· No
If "Yes" state the total amomit $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
• • Yes ·—··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.
p,q7'f·/ER are ,00 mon/`?7{5
I declare under penalty of perjury that the above infomation is true and correct.
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DATE SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
stating all assets. In addition, a p1·isoner 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 ill multiple institutions, attach one certified
statement of each account.

Case 1:06-cv-OOO38—GI\/IS Document 1-2 Filed O1/20/2006 Page 1 of 1
~ 0 6 — 0 3 8
DELA WARE C ORRE C T I ONAL CENTER
SUPPORT SER VI CES OFFICE
MEM ORAND UM
To.- M g U;)uMx.» sE1#.- \—\’lqS`/1
FROM: Stacy Shane, Support Services Secretary
RE; 6 Months Account Statement
DATE.- ®.O_QQ@§Qgg@ ,<}QL5>"`T JAN 20 ZGU5
ttached are copies of your inmate account statement for the months of
Clgmt 1,2sxW it gu>A’
T he following indicates the average daily balances.
MONTH AVERAGE 1>A1LYEA1;ANcE
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Average daily balances/6 months:
Attachments _
cc.- File NM
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