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

Case 1 :08-cv-OO081e—JJF Document 1 Filed O2/07/2008 Page 1 of 2
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
on my Ram
Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
CQQL `DQsl@Q2Q E1" AL . FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER: __
\ Clip · . ··‘OB O8‘l""*
I, i Qflfl / \ lO declare that I am the (check appropriate box)
'PQ _\?:titioner/Plaintiff/Movarit ' " Other p
in the above—entitled proceeding; that in support of my request to proceed without p - ` "``C```
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings . le tha ··-· »A~- g
sought in the complaintfpetitionfmotion. _ _·
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In support of this application, I answer the follow questions under penalty of pe ury: T m V
1. Are you currently incarcerated? ° I ° °No (If "N0" go 4__A_
If "YES" state the place of your incarceration , lt_Jj2,lj 6TZWLC.]llO¢"t5t l l°J?éO{`l
Inmate Identification Number (Required):
Are you employed at the institution? U O Do you receive any payment from the institution? O
Attach or ledger sheet Qom the institution of your incarceration showing or least the gas! six: months ’ e
- I transactions · r
2. - Are you currently employed? ° ° Yes
p a. If the answer is "YES" state the amount of your take—ho1ne 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 r
salary or wages and pay period and the name and address of your last employer- _ 5;, OQ
I ¤"'\¤=¤l<- Q-lDl¤i"l’ ll (lm) Clollaff G. WQSK tor »L;<>?.·’€¢’>’ {o»—.s·1*·,-t,C_;.,t,b P
3. In the past 12 twelve months have you received any money from any of the following sources? *‘ ·
a. ’ Business, profession or other self—employ1nent • · Yes
b. Rent payments, interest or dividends • • Yes , I -
c. Pensions, annuities or life insurance payments · • Yes
cl. Disability or workers compensation payments · • Yes
e. Gifts or inheritances • · Yes `
f. Any other sources V • • 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. (1/ty MHDQMGL 52,fF; Wig I QQ CQGMK5
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. __ , . Case 1 :08-cv-00081-JJF Document 1 Filed O2/07/2008 Page 2 of 2
AO 140 Reverse (Rev. `lG,·"€I3] `
DELAWARE$Eev. 4{U5!
4. Do you have any cash or checking or savings accounts? · • Yes
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property'?
A "Ye @
` 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 suppoit, OR state NONE if applicable.
I declare under penalty of` perjury that the above information is true and correct.
QM 1 -02* g@-ei O
. DATE - . SIGNATURE OF APPLICANT
NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an afiidavit A
p stating all assets. In addition, a prisoner must attach a statement certified bythe appropriate institutional
officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
Ifyou have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account. ·

Case 1:08-cv-00081-JJF

Document 1

Filed 02/07/2008

Page 1 of 2

Case 1:08-cv-00081-JJF

Document 1

Filed 02/07/2008

Page 2 of 2