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

Case 1:08-cv—O0O45-SLR Document 1 Filed O1/22/2008 Page 1 of 2
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A UNITED STATES DISTRICT COURT
Q M- DISTRICT OF DELAWARE
éztifry Zig
Plaintiff APPLICATION TO PROCEED
V. _ L WITHOUT PREPAYMENT OF
;Ww’ y ¢?»‘*fH·£. Ja wwf? [/gre gy/" FEES AND AFFIDAVIT
Defendantfs) p
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l, gn fr? { [@*/0 MJ declare that I am the (check appropriate box)
E PetitionerfPlaintiffflyiovant El Other
in the above-entitled proceeding; tha.t in support of my request to proceed i·.a. =.. . ___., q_ under
28 USC §l915, I declare that I am unable to pay the costs of these proce p_=__ to th relief
sought in the complaint/petition/motion. '``A
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In support of this application, I answer the following questions under pen ity o lie-ea r. .am___,n -
i
I. Are you currently incarcerated? lj Yes lx No (l zll ·*"i -¤-.ié£x _ r
If "YES" state the place of your incarceration ‘ _
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution'?
Artem}: r1 ledger sheer goin the institution of your incarceration showing at least the gust six months '
trarisactforis
2. Are you currently employed? III Yes lyric
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. 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.
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3. In the past I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment El Yes
h- Rent payments, interest or dividends El Yes No
c. Pensions, annuities or Iife insurance payments El Yes Bqlo
d. Disability or workers compensation payments Ellfes U No
e. Gifts or inheritances El Yes l3’No
f. Any other sources U 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 continue to receive. 5 5-Q fg! hw_V%/ y
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_ _ Case 1 :08-cv—OOO45-SLR Document 1 Filed O1/22/ZOQ8 Page of _
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4. Do you have any cash or checking or savings accounts? El Yes Wie
lf "Yes" state the total amount $ ;W’/V'? {1*/ 9/{ A4"! diet: *é’i" #4'¢‘i‘r‘°f"J
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
El Yes 21%
li` "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 NONE if applicable.
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l 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 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-00045-SLR

Document 1

Filed 01/22/2008

Page 1 of 2

Case 1:08-cv-00045-SLR

Document 1

Filed 01/22/2008

Page 2 of 2