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

Case 1 :08-cv-00301-SLR Document 1 Filed 05/21 /2008 Paiée 1 of
(aw. 4/97) UNITED STATES DISTRICT COURT g M AY 2 1 2008
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DISTRICT OF DELAWARE 1 i Q
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Plaintiff APPLICATION TO PROCEED
1 {V \ V. WITHOUT PREPAYMENT OF
* · FEES AND AFFIDAVIT
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Defendant(s) I g Q
F CASE NUMBER:
I, ih Eki A L 2 declare that I am the (check appropriate box)
if Petitioner/Plaintiff/Movant D Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees 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/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? m\Yes D No (If "No" go to Question 2)
If "YES" state the place of your incarceration i wg)? I Qnsi v {OQQIQI-A
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Are you employed at the institution? N Q )Do you receive any payment from the institution? I Q Q )
Qave the igg,@ ug'0n QQ ogt {he ggqfcgg pggigg gt {lg} gjdgk @4 gtgch g ledg sheet from the
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g` gat peguired for ggses Qled pgggygnt Lg ZQQSQ QZZQ4,
2. Are you currently employed? D Yes E/No
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 employment, the amount of your take-home
salary or wages and pay period and the name and address of your last employer.
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 E1 Yes `1@o
b. Rent payments, interest or dividends ¤ Yes Jo
c. Pensions, annuities or life insurance payments D Yes m)Io
d. Disability or workers compensation payments ¤ Yes Z(No
e. Gifts or inheritances yes No
f. Any other sources Yes U 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 ' continue to receive. /»
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Case 1 :08-cv-00301-SLR Document 1 Filed 05/21 /2008 Page 2 of 2
4. Do you have any cash or checking or savings accounts? DYes pf
If "Yes" state the total amount S
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles r other
valuable property? Z//D
¤Yes o
If "Yes" describe the property and state its value. , lg
6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how much you cont 'bute to their sux? OR state NONE if applicable.
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I declare under penalty of perjury that the above informatio nd correct.
__ I \
DATE SIGNATURE OF APPLICANT
CERTIFICATE
(Incarcerated applicants only)

I certify that the applicant named herein has the sum of S on account his/her credit at (name
of institution) .
I further certify that the applicant has the following securities to his/her credit:
I further certify that during the past six months the applicant’s average monthly balance was S
and the average monthly deposits were S .
Date SIGNATURE OF AUTHORIZED OFFICER
(NOTE THE REQUIREMENTIN I TEM 1 FOR THE IMIIATE TO OBTAIN ANDATTACH LEDGER SHEETS
OF ACCOUNT TRANSA CTTONS OVER THE PAST SDK MONTH PERIOD. LEDGER SHEETS ARE NOT
REQUIRED FOR CASES FILED PURSUANT TO 28: USC §2254)


Case 1:08-cv-00301-SLR

Document 1

Filed 05/21/2008

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Case 1:08-cv-00301-SLR

Document 1

Filed 05/21/2008

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