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

F Case 1:06-cv—OOOO1-Gl\/IS Document 1 Filed O1/O3/2006 Page 1 of 3
AO 240 (DELAWARE REV 7/00)
UNITED STATES DISTRICT COURT
-— DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
WITHOUT PREPAYMENT OF
___ V._,. __, _ FEES AND AFFIDAVIT
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Defendant(s) CASE NUMBER: O G " °l
V, I, ·~> ‘°* ""* Q S {R ~ \ Q gg declare that I am the (check appropriate box)
@fP'etitioner/Plaintiff/Movant [I Other in the above-entitled proceeding; that in support of my
request to proceed without prepayment of fees or costs under 28 USC § 1915, I declare that I am
unable to pay the costs of these proceedings and that I am entitled to the relief sought in the
complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
I. Are you currently incarcerated? EYes E No (If "No" go to Questio 2)
(__ If "YES" state the place of your incarceration il, g g
*€>e\».·»~» are Q¤s¤_¤acc.¤ N at @·¤·»—~>'T#» -r ' Deb me t
Are you employed at the institution? I] Yes lE’No I. '
Do you receive any payment from the institution? I] Yes Ejslo
Have the institution till out the certitzcate gortion of this atfzdavit and attach a ledger sheet from the
institution fs) of your incarceration showing at least the gast SIX months' transactions. Ledger
sheets are not required [or cases tiled gursuant to 28: USC §2254. `
2. Are you currently employed? I] Yes [E60
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period and
give the name and address of your employer. Q`-
b. If the answer is "NO" state the 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.
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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 E Yes E’No
b. Rent payments, interest or dividends [I Yes [El/No
c. Pensions, annuities or life insurance payments E Yes E/No
d. Disability or workers compensation payments E Yes E/No
e. Gifts or inheritances [I Yes lEl"No
f. Any other sources E Yes E/NE
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-OOOO1-GIVIS Document 1 Filed O1/O3/2006 Page 2 of 3
4. D0 you have any cash or checking or savings accounts? E Yes Emo
If"Yes" state the total amount {B ")\\ Dr
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or
other valuable property? El Yes El’l€o
If "Yes" describe the property and state its value. X
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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.
I declare under penalty of perjury that the above information is true and correct.
- ` . . ‘r— # 3 .
Date: N \ Signature of Applicant _`

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Case 1 :06-cv-OOOO1-GIVIS Document 1 Filed O1/O3/2006 Page 3 of 3
CERTIFICATE
(Incarcerated applicants only)
(T0 be com Ieied bv rhe inst` ution 0 in arceratiorz
I certify that the applicant named herein has the sum ot`$ fi § on account his/her credit at (name
of institution) I il/i IQIQQ { I .
I further certify that the applicant has the followin securities t his/he c edi : #4 _
ILA A M {hc /We/.5Q—».
I further certify that during the past six months the applicants average monthly balance was S T i ·
and the average monthly deposits were $ Q 2
Date Signature of A&horized Officer
(NOTE THE REQUIREMENTINITEMI FOR THE [NMA TE TO OBTAINAND ATTACH LEDGER
SHEETS OFACCOUNT TRANSACTIONS OVER THE PAST SIXMONTH PERIOD. LEDGER SHEETS
ARE NOT REQUIRED FOR CASES FILED PURSUANT TO 28: USC §2254)
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