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

,.r Case 1 :06-cv—00031-SLR Document 1 Filed 01/17/2006 _ Page 1 of 2 _ `* i
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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_ Plaintiff APPLICATION TO PROCEED
o qys,\’Q,¤.`¢x60i\ WITHOUT PREPAYBIENT OF
E ‘~ fend t(s) .
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I, y-ic-kn (\r\CKi`\\l\ declare that I the (check appropriate box)
° ° L Petitioner/Plaintif1‘YMovant ° ° Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintfpetition/motion.
‘ In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? ° @ ° °No (If "No" go to Question 2)
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. If"YES" state the place of your incarceration | 5; O T ggj; [2 5·;t-L€La;~i- ( ;;;imir1Qir>O & / C/80%
Inmate Identification Number (Required): ZS l§Q§ ii (),‘5l=:>°7 Y 5
Are you employed at the institution? [U Do you receive any payment from the institution? /‘-J U
A Attach tz ledger sheet from the institution of your incarceration showing at least the gas! sbt months ’
transactions -
2, Are you currently employed? ° ° Yes ° ®
ar Ifthe answer is "YES" state the amount of your take-home salary or wages and pay period a
1 and give the name and address of your employer. . e
b. It`tl1e answer is "NO" state ti1e 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 of the following sources?
a. Business, profession or other self-employment • • Yes @
b. Rent payments, interest or dividends • • Yes
c. Pensions, annuities or life insurance payments • • Yes cj;)
d. Disability or workers compensation payments • • Yes · Gin
e. Giiis or inheritances · &
f. Any other sources • • Yes · · l
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.
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Case 1 :06-cv-00031-SLR Document 1 Filed 01/17/2006 Page 2 of 2
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DELAWAliEj§ev. QUE I .
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l 4. Do you have any cash or checking or savings accounts? • • Yes • ®
I If "Yes" state the total amount $ ‘
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
g valuable property? _ ‘
• • Yes · @
‘ 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.
K) o we I .
p I declare under penalty of perjury that the above information is true and correct.
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DATE. - · SIGNATURE OF APPLICANT ` .
NOTE T0 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 duringthe last six months in your institutional accounts.
Il' you have multiple accounts, perhaps because you have been in multiple institutions, attach one certiiied
statement of each account.