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

_ _ Case 1 :05-cv-00877-JJF Document 1 Filed 12/19/2005 Page 1 of 3
gay. aim UNITED STATES DISTRICT COURT
0Q\G DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
° . _ - . FEES AND AFFIDAVIT -
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Defendant(s) . . -
CASE NUMBER: 0 5 - 8 7 7
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I, lie ittgg O r [QW CPA 5* * r' L"! declare that I am the (check appropriate box)
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m Petitioner/Plaintiff/Movant El Other 1 I
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. in the above-entitled proceeding; that in support of my request to proceed without prepayment offices or costs
under 28 USC §1915, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the
relief sought in the complaint/petitionlmotion. g__ Yi ? _ Y _
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated'? D Yes M No (If "No" go to Question 2)
If "YES" state the place of your incarceration
Are you employed at the institution? Do you receive any payment from the institution? __
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2. Are you currently employed? U Yes FLN0
a. If 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 en1ployment,=tl1e amount of your take-home
salary or wages and pay period and the name and address of your last employer. i V
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3. In the past 12 twelve-months have you received any money from any of the following sources?
- a. Business, profession or other self—employment M ¤ Yes ` EI - - No
b. Rent payments, interest or dividends U Yes D No "
c. Pensions, annuities or life insurance payments El Yes El No
d. Disability or workers compensation payments Yes ¤ No
e. Gifts or inheritances El Yes D No
f. Any other sources _ _ p U Ci 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 continue to receive.
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Case 1 :05-cv-00877-JJF Document 1 Filed 12/19/2005 Page 2 of 3 `f i' ~ n
4. Do you have any cash or checking or savings accounts? ¤Ycs I X?.
If "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other V
valuable property?
¤Yes Mo -
Ii' "Yes" describe the property and state its value. I ' _
6. List the persons who are dependent on you for support, state your relationship to each person and
indicate ho ch ntribute to their support, OR state NONE if applicab_ I
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I declare under penalty of perjury that the above information is true and correct. in
to § gf H- Q j/·.,;·-·-—..- _,
DATE SIGNAl URE OF APPLICANT
_` i CERTIFICATE n .
(Incarcerated applicants only)
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I certify that the applicant named herein has the sum of S l on account his/her credit at (name
of institution) l A . .
I further certify that the applicant has the following securities to his/her credit: I
I further certify that during the past six months the appIicant's average monthly balance was S
and the average monthly deposits were S 1- -- .
Date SIGNATURE OF AUTHORIZED OFFICER
HVOIE T`HE REQUIREMENTIN ITEM 1 FOR THEINMATE TO OBTAINAJ\lDATT'ACHLEDGER SHEETS
OF ACCOUNT TRANSACTTONS OVER THE PASTSD{ MONTH PERIOD LEDGER SHEETSARE NOT
REQUIRED FOR CASES FILED PURSUANT TO 28: USC §2254)

M _ Case 1:05-cv-00877-JJF Document 1 Filed 12/19/2005 Page 3 of 3
A0 240A
DELAWARE (REV 4/98)
United States District Court
_ For the District of Delaware
ORDER ON APPLICATION
TO PROCEED WITHOUT
PREPAYMENT OF FEES
Plaintiff
I v. CASE NUMBER:
Defendant I
Having considered the application to proceed without prepayment of fees under
C 28 U.S.C. §l9l5; ·-··—
IT IS ORDERED that the application is:
E] GRANTED;
I] The Clerk is directed to file the complaint I
E] IT IS FURTHER ORDERED that the United States Marshal serve a copy of
the complaint and this order upon the defendant(s) as directed by the
plaintiff. All costs of service shall be advanced by the United States.
EI DENIED, for the following reasons:
· ENTERED this day of , .
Signature of ]udicial`Officer `
Name and Title of Iudicial Officer