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

Case 1:06-cv-00022-KAJ Document 1 Filed O1/11/2006 Page 1 qj,§,., ,,,.,,,,_,@‘ JI
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_ Case 1:06-cv-00022-KAJ Document 1 Filed O1/11/2006 Page 3 of 3
s‘rATE OF rireamsru ' ,_ _' Case Mouser
Forum no. arm rm. ares FINANCIAL AF FIDAVIT
` zs-ram _
IN THE\)l‘I; I Eli rl;} IQ.; di-;l7‘*¢IrCOURT OF [Qing El. Q . , l lB9r
pans ea ltobrnsii. @2]% OW
Plaintiff
. ` FINANCIAL AFFIDAVIT
vs. ,/· ·
L1€gJ lt) AME}?
Defendant ·
I hereby swear that by reason of poverty: `
Z' l am unable to pay the docket fee, cost bond. and other costs of appeal.
’ Cl I am unable to afford counsel to represent me in this proceeding.
El i am unable to pay the judgment assessed against me, I wish to apply for time in which to pay
such judgment.
l hereby submit the following financial affidavit. __
I. Employer: if O C/5* Address:
Length of employment: “ lf unemployed, state reason. physical or otherwise why
you cannot be employed: ' '
lf unemployed, when and where were you last employed?
ll. Income (Monthly) Self Spouse .
A. Wages S O S
B. Welfare S U S
C. Unemployment S U S
D. Parents S 'O 5 _
E. Other S . E S ‘
lll. Family Assets ,D _
A. Cash on Hand S - F. Rentals S O
B. Bank Accounts $ G. Tools ` S is
C. Automobiles S Q H. Equipment $‘ U
D. Real Estate S O l. Jewelry S g
E. Securities, S E J. Other S Q
Stocks, Bonds
IV. Marital Status: El Single E/Married El Divorced El Widowed
Name of Spouse:
Number of children you are supporting and their ages:
V. Debts Monthly Expenses
A. s O A. s O
· e. I s O e. s O
C._____________$;________E C. S T7
‘ D. S Q D. S 0
VI. Education Completed:
I swear, or affirm, under penalty of perjury, that the foregoing financial affidavit is
true and hereby request the following: V
Cl waiver ol payment of docket lee, cost bond and other costs of appeal.
Cl appointment of counsel to represent me in this proceeding.
Cl additional time in which to pay the judgment assessed against me.
DATE; fl'/‘~¤'U\ :)"7£‘
ADDRESS: {gf l { A./—~.¤t Pl-lONE#: D.O.B.;
SUBSCRIBED AND SWORN TO
BEFORE ME: