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

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{ DELAWAREg_F;w. QQ] · _ ‘ ' ¤ fr ¤ ·» · . . - `
UNITED STATES DISTRICT COURT
` DISTRICT OF DELAWARE
V l Judy fgjrphji $97.752 i p
_ P atntirf ‘ APPLICATION TO PROCEED
4 V V. WITHOUT PREPAYMENT OF
‘ 1.. . -— n. , L..,.. ri it » »·»· . . art » FEES AND AFFIDAVIT
I Defendant(s) .
" CASE NUMBER:
· . *2 O 8 ‘ O 1 8 2:.
. I, declare that I am the (check appropriate box)
y · ‘ =D` W D'Dh { ```DI • • other i
in the above-entitled proceeding; that in support of my request to proceed without pr pa r r : -. 1: Ir.? u
28 USC §l9I5, I declare that I am unable to pay the costs ofthese proceedings . that _. am entitled to the reli f
sought in the complaintfpetition/motion, A A U Q _
` In SUPPOVI of this 9·PPli¤¤li¤¤ I BHSWBI the following questions under penalty of pe ury; N A ' H
’ - U DISTFIIGTOF DELAWAR . _
1. - Are you currently incarcerated? ° °No (If "No" go to Question 2)
. J If "YES" state the place of your incarceration .. if is- p . Qs ·l" il ii. ` IU
Inmate Identihcation Number (Required): i _
Are you employed at the institution? _Afg__Do you receive any payment from the institution? /l/0 A
i Attach o ledger sheet Qom the institution of your incarceration showing at least the past six: months '
transactions pp U p A
2. Are you currently employed? ° ° Yes -- l
a. Ifthe answer is "YES" state the amount of your take-home salary or wages and pay period a A
and give the name and address of your employer.
b. If the answer is "NO" state the date _of your last -ernployment,,_the amount of your take—home
U . salary or wages and pay period and the name and address of your last employer.
3. t In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other seltiemployrnent • • Yes
b, Rent payments, interest or dividends p ‘ • · Yes
c. Pensions, annuities or life insurance payments · · Yes t- i ifi
rl, Disability or workers compensation payments ' ' Yes -—-_ I
e. Gifts or inheritances ' ' Yes .. .·s.
f. Any other sources • • Yes `
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.
I- I 1 »

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` V AO 240 Reverse (Rev, 1.Di'tI3) .
DELM‘r'M'tE$Eev, . _
I Do YOU. have BUY {7851] O1' Ch€Cl<.l1'].g OI S8ViI1gS ElCCGU.[llCS? ° ° Y€$
·It” "Yes" state the total amount 5 ‘
`S. e Do you own any real estate, stocks, bonds, securities, other tinancial instruments, automobiles or other
, valuable property? ‘ I
I 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 I
indicate how much you contribute to their support, OR state NONE if applicable.
I /%¤te. ·
_ I declare under penalty ofpeijury that the above information is true and correct.
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 certilied by the appropriate institutional r
ofticer showing all receipts, expenditures, and balances during thelast six months in your institutional accounts.
If you have multiple accounts, perhaps because you have heen in multiple institutions, attach one certified
statement ofeach account. I p

Case 1 :08-cv-00018-JJF Document 1 Filed O1/O9/2008 Page 3 0f 3
STATE OF DELAWARE
DEPARTMENT OF CORRECTION
BUREAU OF ADULT CORRECTION
HOWARD R. YOUNG CORRECTIONAL INSTITUTION
P.O. BOX 9279
WILDIINGTON DE 19801
(BUSINESS ADDRESS)
Memorandum
To: Andre Wright, SBI # 592757,1F-7
, From: Business Office
n
1 Date: November 13, 2007 `
` L
_ 7 Re: Response to your letter.
A Mr. Wright,
You have no transaction so you have no history.

Case 1:08-cv-00018-JJF

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Filed 01/09/2008

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