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

Case 1:05-cv—0O883—SLFl Document 1 Filed 12/22/2005 Page 1 of 3 ‘
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I (Rev-4/97) UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
_ APPLICATION TO Paocsan
am ‘ wmtour PREPAYMENT on
V FEES AND AFFIDAVIT
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CASE NUMBER: 6 _ l p _ _
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Petitioner/Ptaintiff/Mevant Other ·;_ `
in the above-entitled proceeding; that in support of my request to proceed
or costs under 28 USC §l9l5, I declare that I am unable to pay the _Q` ``. ._,
that I am entitled to the relief sought in the complaint/petition/motion. C '
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)
If "Yes" state the place of your incarceration
Are you employed at the institution? Q Do you receive any payment from the institutic·n?1___
_•_· · t e ' t` u S. ut •· ce S te •u •S•S • •. a Ht, a • att c . dve he •_• t e
igstjtutienlsl ef ygu; ineageeratleg shewlgg et least the past Sl megtl;is’ tregsactiegs. llge ledger
sheet ls get geguired fe; eeses lllegl pugsgegt tg 2§: LJSQQ §22§4,
2. Are you currently employed? - Yes @
a. lf 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” 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.
3. In the past twelve months have you received any money from any of the following sources? I
a. Business, profession or other self·employment Yes I-H
b. Rent payments, interest or dividends Yes
c. Pensions, annuities or life insurance payments Yes p _
d. Disability or workers compensation payments Yes
e. Gifts or inheritances {cfs-) 0
ti Any other sources Yes ®
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—0O883—SLFi Document 1 Filed 12/22/2005 Page 2 of 3
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4. Do you have a cas-h or checking or savings accounts? Yes
If"Yes" state the total amount S .
SQ Do you own any real estate, stocks, bonds, securities, other financial instnlgwnts, automobiles or
other valuable property? Yes Clig )
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.
I declare under penalty of perjury that the above information is true and correct. D
/ ?Cl 0 ST I l T .7/f? I
D TE SIGNATURE OF PLICANT

Case 1:05-cv—0O883—SLR Document 1 Filed 12/22/2005 Page 3 of 3
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