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

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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Piatmirr APPLICATION TO PROCEED
. ~ L gp. . . _ , WITHOUT PREPAYMENT OF
`-`· * =E.‘ "° =-it · ·-~-· FEES AND AFF IDAVIT
Defendant(s) __ __ _
_ _ CASE NUMBER: Yjg 877 TTF
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I, —- ~a · ---- . it -·t ·-·- - ·- :- declare that I am the (check appropriate oox)
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• • Petitioner/PlaintiffYMovant • • other

in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or cos sunder,
28 USC §I9I 5, I declare that I am unable to pay the costs of these proceedings and that I am entitled g g.
sought inthe complaint/petition/motion. - l

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In support of this application, I answer the following questions unjder penalty of perjury: ’
‘ -
l. Are you currently incarcerated? ° °{es ° @ $0 ; (lf "No" go to Question 2) gr E
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lf "YES" state the place of your incarceration _
Inmate Identification Number (Required): mi ` _"
Are you employed at the institution? Do you receive any payment from the institution?
Attach cz ledger sheer @0711 the institution 0{ your incarceration showing atleast the QGSI sir mon/hs"
tran.saczi0rzs Y _ _
2. Are you currently employed? ° ° Yes °
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.
b. lf the answer is "NO" state the date of your last employment, the amount of your take·home
Sétl ' OK d pay petit;. _ andthe name and addre fyour last employer,
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3. In the pas `”""'”*’*Fig-· i ‘ s have you received any mone§om any ofthe following sources?
a. Business, profession or other seliiemployment _ · • Yes · · No
b. Rent payments, interest or dividends · · Yes · · No
c. Pensions, annuities or life insurance payments · · Yes · · No
d. Disability or workers compensation payments · · Yes · · No
e. Gifts or inheritances · · No
f. Any other sources · • No .
lf the answer to any of the above is "YES" describe each source of money and state the amount
received AND wl at o t `ll t` t · `I . ·e C- ’ . ~ · Fe;.
t y uexpcc you wi con rnue oteceue J / I léli F w! _1 _
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Case 1 :05-cv-0087 -.hlF Doc rpgdgi QQ Filet; O§é2;2/BGG? Page 2 of S- 2
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4, D0 you have any cash or checking or savings accounts? ‘ · · Yes
lf "Yes" state the total amount S l
5. Do you own any realestate stoc :_____;_•,g ;___gm__J Q_ gies, other financial instruments, automobiles or other
valuable property? P ‘ ·- _'
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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 contri t thenra p if U
D gi g I i P ` ‘· ’ . _
I declare under penalty of perjury that the above information is true and correct.
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DATE SIGNATURE OF APPLICANT
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
ofiicer showing all receipts, expenditures, and balances during the lastsix 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. _

Case 1:05-cv-00877-JJF Document 30 Filed 03/22/2007 Page 3 of 3
O
Your New Benefit Amount
BENEFICIARYS NAME: ROLAND C ANDERSON Mm
Your Social Security benefits will increase by 3.3 percent in 2007, because of a rise in the cost of
living. You can use this istter when yea need preor or your oenent amount to receive food stamps, rent
subsidies, energy assistance, bank loans, or for other business.
How Much Will I Get And When? .
• Your new monthly amount (before deductions) is . L ...-- - _ -
• The amount we are deducting for Medicare medical insurance is _..s._ ....,._ ~
(If` you did not have Medicare as of Nov. 15, 2006,
or if someone else pays your premium, we show $0.00.)
• The amount we are deducting for your Medicare prescription drug plan is
(If you did not elect withholding as of Nov. 1, 2006, we show $0.00.)
EQ The ?"P¥’lmt Wfflfilfglitllg f°U"?lQ .... .. .,,5.., .
""“` (If you did not elect voluntary federal tax withholding as of l ``_ ` - I "
Nov. 15, 2006, we show $0.00.)
• After taking any other deductions, we will deposit
into your bank account on Jan. 3, 2007.
If you disagree with any of these amounts, you should write to us within 60 days from the data U
you receive this letter.
What If I Have Questions?
Visit our website at www.s0cialsecurity.g0v 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,
1-800-325-077 8. If you are outside the United States, you can contact any U.S. embassy or consulate
office, or the Veterans Affairs Regional Office 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 office.
SUITE 200
920 W BASIN ROAD ,_
NEW CASTLE DE 3
BNC#: O6B1368F49623 " Over )·
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