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

Case 1:05-cv-00877-JJF Document 12 Filed 07/05/2006 Page 1 of 2
AO 2-10 (Rev IUFU3)
DELAW.-\R.E£Rrv. MGS; ·
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
CD r
Plaintiff APPLICATION TO PROCEED
v. WITHOUT PREPAYMENT OF
.»· FEES AND AFFIDAVIT
Defendant(s)
case NUMBER: (jr E7'! CUP}
l, __ _ D (O· 0*¤»f declare that I am the (cheek appropriate box)
E Petitioner/Plaintiff/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, I declare that I am unable to pay the costs of these proceedings and that I am entitled to ge relief
sought in the complaint/petition/motion. 'é'_¤:° ,,,, r
In support ofthis application, I answer the following questions under penalty of perj uty: I 1
UI ” "
l. Are you currently incarcerated? El Yes iq No (If"No" go to Question 2):.
EE
It` "YES" state the place of your incarceration t . .... 9 H
Inmate Identification Number (R%;1ired :
YT .
Are you employed at the institution? rl Q,. A Do you receive any payment from the institution?
Attach rr led er sheet mm the instirurion 0 me- im,·arceration showin at least the ms: sir rnonr/is'
1mn.rac.rior:.r
2. Are you currently employed? El Yes BZ No
a. lf 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. 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 namegand address of your last employer.
c...,M {OL/O' cow/57
3. In the past 12 twelve months have you recei `d any money from any of the following sources?
a. Business, profession or other self-employment D Yes El No
b. Rent payments, interest or dividends ¤ Yes El No
c. Pensions, annuities or- life insurance payments El Yes U No
d. Disability or workers compensation payments [ Yes El No
e. Gifts or inheritances E1 Yes E1 No
f. Any other sources El Yes El No
If the answer to any of the above is "YES" describe each source of money and state the amount
received AND what you expect you will ontinue to receive.
[ Q Z`?.

Case 1:05-cv-00877-JJF Document 12 Filed 07/05/2006 Page 2 of 2
A0 240 Reverse (Rev. ltl.'03)
DEL.AWAREt§ev. 4/OS!
4. Do you have any cash or checking or savings accounts? CI Yes ) If "Yes" state the total amount $ _ _
5. Do you own a11y real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
valuable property? ,
D Yes El No
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 2*0/VE if applicable.
6 `O .-Cl`; il- DFP?
I declare under penalty of perjury that the above information is true and correct.
rr% tj 04 MJ ti. ¢i»J»4u·-v . » _
ATE SIGNATURE OF APPLICANT
NOTE T0 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.