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

Case 1:06-cv-00018-JJF Document 1 Filed O1/06/2006 Page 1 of 2
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UNITED STATES DISTRICT COURT
@0 DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
5 [gg é Qj; i **3 FEES AND AFFIDAVIT
I)et`cnclant(s) ._ J.
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]_ y 7. $_,_(L,_{;/J1"prJ_ yi {,q17L‘__ ___ _ A __ declare that I am the (check appropriate box)
E Pctitioner/Plaintift7Movant ij Other
in the above-entitled proceeding; that in support ofmy request to proceed without preiiayinentiof tees ririeostsluiider ` ` `.
23 USC §l9l5, I deelare that I ani unable to pay the costs of these proceetlings and that lyam-entitled to the'1‘e_l_ieti`
sought in the complaint/petition/motion. _
In support ot` this application, I answer the following questions under penalty of perjury: Q
l. Are you currently incarcerated'? E Yes E No (It"`No" go to Questi:oni2)__ _ ,_1. pi
lt` "YES" state the place ol` your incarceration A _ ___ )__ ___f ____y _”____ _
Inmate Itlentiticatinn Number (Required); _ _ __ i_#__ #_#
Are you einployetl at the institution`? _ Do you receive any payment trom thc institution? ____
Atrrrcfz rt /ei:t'ger sheet fiprtr J/ig;Q@{t‘1i·r1`r1rr oft·*ruir*jg;g;g;qr‘rt!irJi1 .r}trn1¤ir2g or the [sus! six motir}r.·; `
rm·n.s·rie1a·nz;g
2. Are you currently einployerl? E Yes E] No
‘ a. Ifthc answer is "YES" state the amount ot` your take-home salary or wages and pay period a
and give the name anal atlclress ot your employer.
li. lftlte answer is "NO" state the rlate ol` your last employment. the amount ol` your talte-liorne
salary or wages and pay pcriotl anti the naine and atlrlress otyour last employer.
I. ln the past I2 twelve tuontlis have you reeeiyetl any inoney troin any ol` the f`oliou·ing st»nn.·es`.‘
a, Business. protession tn atlier sell-eniployineiit U Yes L1 No
h. Rent payments. interest or rliyitlenils U Yes rt \~»
e. Pensions. annuities or lite iiisnranix psiynient: It Yes tt isi.
Li. t`rl` \‘i.`t_\]`i~§Ql x g`t'll]][\L_‘lI<}l[|r*ll [lil} lllljtlin U Yrt;5 l_i \\jii
e. (iiits or inheritance-~ Et Yes ¤. ‘i-. it
l`. Any other stances PQ Yes . ,.
llthu answer to any wl the iii · E *~ ` ile rest tie i- —*.i»·ii¤;e iitniiiiiegr anti sirius ui.- .:- ri
ri;eeiierl,ts\*`]Z¤ iyligu jrozz = - ~*· "*i **·*‘- A `- V {Og) {2 ,l,>___-.-` - ‘ 5 , , A- it
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Case 1:06-cv-00018-JJF Document 1 Filed O1/06/2006 Page 2 of 2
Al') 240 Reverse [Rev IWUS)
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4. Do you have any cash or checking or savings accounts? El Yes EQ No
l{"'Yes" state the total amount L
5. Do yOU 0\Vtt {U1)/t`€£1l estate, SlOL;l·{S, b0l'IClS, S€Ct1l'lli€S, 0ti"lCl' lill£tl`tCiill iI1S[I'LllTlC|'llS, £ttIlOlt'l(}l7llC5 UI' Ui.l'lCI'
valuable property'?
Xi Yes C1 No
if ··Y€S·• describe the property and state its value. H·nt)<,·1L r‘r•-§»Fg, CT · Cglilir `l'7° ’/G 9}% /Ut€‘§·‘tD —· Cipg ··—¤-*’ •°>@cr¤·Q> cvs! U elf Mrlczs Z5/Cr D ¤ iter;
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Gr List the persons who are dependent on you tor support, state your relationship to each person and
indicate hevv nruch you contribute to their support. OR state NON]! ifapplieable.
I declare under penalty ol` perjury that the above irrtirrmation is true and correct.
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DATE rNATU - PPE.,l(,/\N"
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NOTE TO PRISONER; .=\ Prisoner scek.ing_5 to proceed without prepayment of fees shall snhrnit an
alTitlavit stating all assets. In atlrlititrn. a prisoner must attach a statement eertil`ietl by the zrpprrrprirrte
institutional eflicer showing all receipts. c:·tperrrliturus. arrrl balances during the last six nrontlrs in tour
lllSIi[lI{iDII£\i ZICCUIIIITS. }'t1tI IHH/U1TIlIlti[¥lClICC{||Il'll$»[.}U]`l]i.|}.}S l)t3CtllISl2 ylltl hilt-’t l’H)t2I1 lll Itllllliltlt
institutions, attach one certilictl srraturnerrr ul' uartr zrrrrrrrrrrt.