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

» Case 1 :05-cv-00877-JJF Document 73 Filed 11/14/2007 Page 1 of 2
AO 240 (Rev. I0/03) .. " l i _
DE1.»AWARE!Rev. 4/05]
UNITED STATES DISTRICT COURT Z
DISTRICT OF DELAWARE _
.._.....
Piamarr APPLICATION T0 PROCEED
V. it WITHOUT PREPAYMENT OF
6·€¢·@'-Vg _ FEES AND AFFIDAVIT
Defendant(s) I
. T ` CASE NUMBER: f ·
L &¤»·~<' II declare that I am the (check appropriate boxj
E Petitioner/Plaintiff/Movant D Other p i I
in the above·entitled proceeding; that-in support of my request to proceed-without prepayment of fees or costs under
28 USC §1915, I declarerhat I am unable-to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion. p _ V -
In support of this application, I answer the following questions under penalty of perjuryr ,
l. Are you currently incarcerated? E Yes No (If "No" goto Question 2)
If "YES" state the place of your incarceration ` _
l . Inmate Identification Number (Required): ~ -
Areyou employed at the institution? I Do you receive any payment from the institution?
. Attach o ledger sheer from the institution of your incarceration showing at least the past soc months
y transactions . I
7 _ ` I . i
I 2. Are you currently employed? E Yes E No ·c
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. -3 p. . . _ _
b. If the answer is “NO" state the date or your last employment, the amount of your take-home
salary or wages and pay period and the name andaddress of your last employer. U .
5*252 a=r$&;» /Z$;_(»7,M__ p_ , y · r .
`3. In the past 12 twelve months have yo received any money from any ofthe following sources?
a. Business, profession or other self-employment U Yes ¤ No I
b. Rent payments, interest or dividends E1 Yes B No -
c.. _ . Pensions, annuities or life insurance payments . . IJ Yes » D No c
p dr _ Disability or workers compensation payments . p _ . U Yes - . ¤ No . . . e
I _e. v_ Gifts ocinheritances ._ . _ . p __ _ _ .-_ D Yes. ( -- El No
` ti _Anyothersotu·ces_ , _ ,._. a _ , Yes D No-_
I If the answer to any ofthe above is "YES" each source of money state the amount I
received AND what you expect you will continue to receive. [ Q _; JQ -
. i . ; Q

, Case 1 :05-cv-00877-JJF Document 73 Filed 1 1/14/2007 Page 2 of 2
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A0 240 Reverse (Rev. I0/'GS} .
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4. Do you have any cash or checking orlsavings accounts? D Yes No _
If "Yes" state the total amount S . an ll
5 . Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ’: _ r-1;, _
l a - A Yes C1 No, : _. 1 .
If "Yes" describe the property and state its value. { _ l l .
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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. ·
Ideciare under penalty of perjury that the above infomation is true and correct. ·
. L . - i .
_ I ` ` ' 3 . I
/,¢{·~e<> ty A 7 V i
DATE ‘ ‘ _ SIGNATURE OF APPLICANT 1 · `
NOTE TO PRISONER: · A Prisoner seeking to-proceed without prepayment of feesshall submit an
aftidavitstating all assets. In- addition, a prisoner must attach a statement certified bythe appropriate
_ institutional officer 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 p
institutions, attach on certiiied statement of each account.