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

Case 1:08-cv-00011-GIVIS Document 1 Filed 08/15/2007 Pagé 1 Of 2
UNITED STATES DISTRICT COURT FOR THE
EASTERN DISTRICT OF PENNSYLVANIA
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Case 1 :08-cv-00011-GIVIS Document 1 Filed 08/15/2007 Page
STATEMENT IN SQPPQRT OF REQUEST TQ PROQEED IN FOQMA PAUPERIS
Full name of Plaintiff
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Defendant(s) .
I, E)! [ if Zjx { )S ` , declare under the penalty of perjury, that I am the plaintiff in
the above·entitled case; that in support of my motion to proceed without being required to prepay fees, costs, or give
security therefor, I declare that because of my poverty I am unable to pay the costs of said proceeding or to give security
therefor and that I believe I am entitled to relief
1.) Are you presently employed? Yes D4; D
a.) If the answer is "yes", state the - ount of your salary or wages · er month, and ive the name and address
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b.) If the answer is "no", state the date of last employment and the amount of the salary and wages per month
which you received.



2.) Have you received within the past twelve months any money from any of the following sources?
a.) Business, profession, or form of self·employment? Yes CI No 6/-\
b.) Rent payments, interest, or dividends? Yes CI No Elf
c.) Pensions, annuities, or life insurance payments? Yes D No 9/
d.) Gifts or inheritances? Yes Cl No 9/
e.) Any other sources? Yes 0* No U
If the answer to any of the above is "ye · ", describe each source of money and state the amoimt receiyed from
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3.) Do you own cash, or do you have money in a checking or savings account? Yes 5 No CI 5 gp IU,
If the answg is "yes", state the togl value of the items owned.? _ _ _
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4.) Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (excluding
ordinary household furnishings and clothing)? Yes CI NoD""
If the answer is "yes", describe the property and state is approximate value.


5.) List the persons who are dependent upon you for support, s te your relatio hip to those persons, and
indicate how mucluou contribute toward their s po ' bl —’ —- Y- . ` .
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p_ I declare under the penalty of perjury that the foregoing ls true and correct.
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EXECUTED ON `— I I `O gy; MM/J
(Date) (Plaintiffs Signature)

Case 1:08-cv-00011-GMS

Document 1

Filed 08/15/2007

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Case 1:08-cv-00011-GMS

Document 1

Filed 08/15/2007

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