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

Case 1:05-cv—00893-Gl\/IS Document 1 Filed 12/28/2005 Page 1 of 2
A (Rev. 4/97) UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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_ LJ P1 . {ff APPLICATION TO PROCEED
am ‘ wrrnour PREPAYMENT or
V FEES AND AFFIDAVIT
"\\'\ CA.-1 {L}; Xi \{‘>%Q;` , Qi; A §
Defendant(s) l
__. ` CASENUIVKBER: Q 5 — 8 g 3
I, ,§p:§M y ]i·{‘gg X3; `, declare that `
Petitioner/Plaintiff/Movant Other _
. . . . . DEC 2 8 2005
1n the above—ent1t1ed proceeding; that rn support of my request to pro eed Jithout prepayment f fe s
or costs under 28 USC §l9l5, I declare that I am unable to pay the cost D _ ` s a d
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:
1. Are you currently incarcerated? @ No (If"No" go to Question 2) I
as as · · Q im H' ` in \ W I ` · I Li .."‘i .»
If Yes state the place of your incarceration ;j\ 5 .3 ; K ( g·,§·· $9;;* Mg il, 33§\ 33 3§3§3 im L lt
Are you employed at the institution? Do you receive any payment from the institution? EK `Q
I-Iave the institution fill out the certificate portion of this affidavit and attach a ledger sheet from the
institutionisl of your incarceration showing at least the past SIX mon‘ths’ transactions. The ledger
sheet is not required for cases filed pursuant to 28: [JSC §2254.
2. Are you currently employed? · Yes No
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.
b. If the answer is "NO"tstate 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.
3. In the past twelve months have you received any money from any of the following sources? A
a. Business, profession or other self-employment Yes No I li
b. Rent payments, interest or dividends Yes ·
c. Pensions, annuities or life insurance payments Yes Vo)
d. Disability or workers compensation payments Yes Noi
e. Gifts or inheritances Yes N`.6
f. Any other sources Yes Qly
If the answer to any ofthe above is "YES" describe each source of money and state the
amount received AND what you expect you will continue to receive.

Case 1:05-cv—00893-G|\/IS Document 1 Filed 12/28/2005 Page 2 of 2
4. D0 you have a cash or checking or savings accounts? Yes No
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If "Yes" state the total amount $ =k’_ .
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or
other valuable property? Yes {N?
If "Yes" describe the property and state its value. -
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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. _ V- a»»
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I declare under penalty of perjury that the above information is true and correct. I
. A it . . » 1/-
DATE J 1 SIGNATURE OF APPLICANT