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

Case 1 :05-cv-00877-JJF Document 38 Filed 06/14/2007 Page 1 of 3
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UNITED STATES DISTRICT COURT cl;
DISTRICT OF DELAWARE
Plaintiff APPLICATION TO PROCEEED
V. WITHOUT PREPAYMENT GF
6-@@*4/F FEES AND AFFIDAVIT
Defendant(s) _
` CASENUMBER: O§"~QP? 7 ,7] I-C
l, fgémd declare that I am the (check appropriate box)
lj PetitionerfPlaintiff/Movant El Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, l declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petitionfmotion. .
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? El Yes E No (lf "No" go to Question 2)
If "YES" state the place of your incarceration “
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet Qorn the institution of your incarceration showing atleast the gast six months '
transactions
2. Are you currently employed? E Yes E No ‘
a. Ifthe 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.
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 yo received any money from any of the following sources?
a. Business, profession or other self—employment El Yes U No
b. Rent payments, interest or dividends El Yes El No
c. Pensions, amiuities or life insurance payments D Yes El No
d. Disability or workers compensation payments U Yes D No
e. Gifts or inheritances EJ Yes U No
f Any other sources fl Yes El No
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. E / / é [ L JC)
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Case 1 :05-cv-00877-JJF Document 38 Filed 06/14/2007 Page 2 of 3
A0 240 Reverse (Rev. I0/03)
DELAWARE!Rev. 4/U5!
4. Do you have any cash or checking or savings accounts? El Yes X No
If "Yes" state the total amount 33
5 . Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property'? p
~ Yes ¤No
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.
I declare under penalty of perjury that the above infomation is true and correct.
DAT SIGNATURE OF APPLICANT e
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 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
institutions, attach one certified statement of each account.

CaseYO5—cv-00§;JJF D§ument 38 Q Files 06/14/2007 Page 3 of 3 -
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‘ BEN·EFICIARY’S_ NAME: aotano c mnaasou sm _'
. l Your Social Security beneits will increase by 3.3 percent in 2007, because of a rise in the cost of ·i `
1r+a¤.g.You aaa use uno iootss wasn yeu asso poser or your cement amount to receive food stamps, rent
subsidies, energy assistance, bank loans, or for other business. » i ‘
Hgw Much Will I Qet And Eben? p _ p ‘ - .
· • Your new monthly amou.nt`(before deductions) in · r - ~
• The amount we are deducting for Medicare medical insurance is _ .j l_. —
i {If you did not have Medicare as of Nov. 15, 2006, p . ` S o
or if someone else pays your premium, we show $0.00.) _ · _ S
. • The amount we are deducting for your Medicare prescription drug plan is p ·
(If you did not elect withholding as of Nov 1, 2006, we show $0.00.) _ 1 - I
.--.--;_’1a¢.ee2m1¤ we as dsdueiss f (If you did not elect voluntary federal tax withholding as of 1 - U
Nov: 15, 2006, we show $0.00.) _ p _ p
• Amer taking any other deductions, we vdll deposit ·_ .
i into your bank account on Jan. 3, 2007. . _ i
If you disagree with any of these amounts, you should write to us within 60 days from the date _
` you receive this letter. ·. _. r ’ . p ‘/.
What If I Have Questions? e ` .
i Visit our websiteat www.soe·ialsecur·£ty.gcv for information about Social Security Or, call
1-800-772-1213 and speak to a representative from 7 a.m. until 7 p.m. on business days. Recorded
information and services are available 24 hours a day., Our lines are busiest early in the week and early
_ in the month; it is best to call at other times. If you are deaf or hard of hearing, call our TTY number, ‘
1-800-3250778. If you are outside the United States, you can contact any U.S. embassy or consulate
_ office, or the Veterans Aii"an·s Regional Oiiice in Manila. Have your Social Security claim number _
available when you call or visit and include it on any letter you send to Social Security If you are inside -
the United States, you also can visit your local ofdce. p I
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