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

Case 1:06-cv—OOO17-Gl\/IS Document 1 Filed O1/O9/2006 Page 1 of 2
\t_>2-ltlil2‘ex· Illftftl
.}Fl.A'.\ AHF itil-~. rl,'L'5l
.4 UNITED STATES DISTRICT COURT .
DISTRICT OF DELAWARE
2 ‘· 5 QL] M- gi IP`.
‘ i¤iaiaiin‘ APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
td nl .-1 Mt im. iU»—F.._ri ..l rises AND Arrimvtr
Det`endant(s) l - jr
CASE NUMBER: ` `
I. {Atl QQ {tgp? dp ‘¥ T . declare that I am the (check appropriate bloat;
° Petitioner/Plaintiff/Movant ° ° Other
in the above·entit1ed proceeding; that in support of my request to proceed without prepayment of fees orcosits under
28 USC §I9l5. I declare that I am unable to pay the costs of these proceedings and that I arn entitled to the relief
sought in the complaint/petitionfmotion.
In support of this application, I answer the IDIIOWIIIQQIIESCIOHS under penalty of peirjuryzl . _` i y I I
I. Are you currently incarcerated? ° "Qes ° °No (If "No" goito Question 2) i ‘ i
lf "YES" state the place of your incarceration r ily ; · i* , rr,-.-» we i fi. r -‘
Inmate Identification Number (Required): 2 fj .§` QZ
Are you employed at the institution? It Do you receive any payment from the institution? [ti ii}
Atmch tz led? er sficet groin the iristirtihon of [OEMi;i’1'C`LI}'C£?f'CIIIOI1Sr’10\t‘IF1g at {eas! the gosr sir m0m‘lzs'
1rwi.»·uctioi·is /
2. Are you currently employed? . • Yes ° I No
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
7,/ A_ alary or wages and pay period and the name and address of your last employer. I _ . . L V.
'j_¤"D JV M"-.] »=.’»Q¤»·,ri;T·lb Wi-wl ·“’ M Mt.-·· viii 5 erm; i —· git iliiw 0*-·'>”i`l{ Ok
3. In the past I2 twelve months have you received any money from any of the fol/Ibwing sources? l at —; gt VQ,
a. Business. profession or other self-employment • · Yes $0
b. Rent payments, interest or dividends • · Yes ·‘ No
c. Pensions, annuities or life insurance payments * • Yes ··/No
d. Disability or workers compensation payments · · Yes · ·’§/o
e. Gifts or inheritances · - Yes · ·’No
t`. Any other sources · {Yes · · No
lf the answer to any of the above is "YES" describe each source ot` money and state the amount
received AND what you expect you will continue to receive. ,
my ’U"·’sl`¤¤i" 52:-6;: 45;-+i»¢·-.·r.·»— $2 O ·°;¢>l" A r>··:»z·i/Q··*‘-” ’i»»'*·_/ G ·?iM~ race-`°’2‘·

Case 1 :06-cv-00017-GIVIS Document 1 Filed O1/O9/2006 Page 2 of 2 r
-\t_i 2411 liuvvrsu {low lll/(Bl i 7
T>Fl.~\‘.\ .\ltF will-·» 4. nit
4. Do you have any cash or checking or savings accounts? • · Yes M
If "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? K
· · Yes · t`o
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.
No it =€’
l declare under penalty of perjury that the above information is true and correct.
. r . "'° ‘ . t ‘
AQ. »;.# -0 2 t‘ if . ’· + / . _
DATE ,. y "' J? SIGNATURE OF APPIJCANT
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 during the last six months in your institutional accounts.
lf you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.