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

Case 1:06-cv-00003-SLR Document 1 Filed O1/O3/2006 Page 1 of 2
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GQ,\G\ UNITED STATES DISTRICT COURT
Q DISTRICT OF DELAWARE
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riamnrr APPLICATION TO PROCEED
_ V. l/,_ _ WITHOUT PREPAYMENT OF
· l4[;¤1·;L·fy,;t I 2Zn».»ne*5 A. L JJ/t» FEES AND AFFIDAVIT
Defendant(s) ,- E5 ..- 3
CASE NUMBER: `J
I, L.,•&9t\*\B V\ L t ` u t` vi fl 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 prepayment of fees_ n.d.er...,...,
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings ;1rrd‘tha"t”I'aii;i'e`r1"§i'fle;j;tdT!1e relief ,
sought in the complaintfpetition/motion. \ l' j`
t I ·
In support of this application, I answer the following questions under penalty ofpé1·jury:\ JMX i 3 mm t
l. Are you currently incarcerated? °/°{es ° °No (If "No" gtgto Qu_,esJ,ion.2)»A;;q¢q-1:EgiiT}”"j
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If "YES" state the place of your incarceration 22 KGLOB VC r·"•·*@£3k`+Q[$i@3‘E`gQ`F ZF'
Inmate Identification Number (Required): E Z g _
Are you employed at the institution? tit? Do you receive any payment from the institution? {Qi
Attach cz ledger sheet from the instittrtiotz of voter i'ncnrcemtion sfiowing at {east the geist sb: months '
tmnmctions
2. Are you currently employed? ° ° Yes °*/No
a. Ifthe answer is "YES" state the amount of your take—bome 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-homei
salary or wages and pay period and the name and address of your last employer.
3. In the past l2 twelve months have you received any money from any of the following sources? _
a. Business, profession or other self-employment · · Yes I
b. Rent payments, interest or dividends · · Yes · biol
c. Pensions, annuities or life insurance payments · • Yes • ¤
d. Disability or workers compensation payments · · Yes •
e. Gifts or inheritances · • Yes · o
f. Any other sources · · Yes · No it
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-00003-SLR Document 1 Filed O1/O3/2006 Page 2 of 2
AO 2451 Reverse (Rev. I0/G3)
DELAWARE tRev. 4£06l
4. Do you have any cash or checking or savings accounts? • • Yes
_ lf "Yes" state the total amount $
5. D0 you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? `K
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.
to 0 to 6
I declare under penalty ot` perjury that the above infomation is true and correct.
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ng; . gig y,u5 c .
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 prisoner must attach a statement certified by the appropriate institutional
ofiicer 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 in multiple institutions, attach one certitied
statement of each account.