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

_ Case 1 :07-cv-00845—G|\/IS Document 1 Filed 12/26/2007 Page 1 of 3 .
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DELAWAR.El§ev. QD5) V ` - · _, , 1
UNITED STATES DISTRICT COURT
- DISTRICT OF DELAWARE ‘
iii:-zaqrigjy r {_ {£é;;g.;/;// p
y rrsianrr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
FEES AND A 5
Defendant(s) - ii 8 I l ,
CASE NUMBER: l
I, —é · G {bt1xJ¢€/ j _ declare that I am the (check appropriate box) U
° ° Petitioner/Plaintiff/Movant ° ° Other Q
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l915, I declare that I am unable to pay the costs of these proceedings an at a ntitled to the relief Q
sought in the complaint/petition/motion. Qi R l `` R it ` it ‘ e {
In support of this application, I answer the following questions under penalty of peri : 6
l. Are you currently incarcerated? °/§ es ° °No (If "No" go Que n 2) . L
· t.I§ i“i`:“o ‘
If "YES" state the place of your incarceration owrara/i l p 22%/ » L - e {i:... »!i. _Qr ,__,¤
Inmate Identification Number (Required); 55`.z¤=·* £§":’p 5 Q I
Are you employed at thelinstitution? /i/0 Do you receive any payment from the institution? [5;/Q l
l Attach a ledger sheet {gem the institution of your incarceration showing at least the past six: mont/is ’ L
transactions ./ - . j
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2. Are you currently employed? ° ° Yes No r
a. If the answer is "YES" state the amount of your take—horne 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 aniount of your take-home
salary or wages and pay period and the name and address of your last employer. Q
3. In the past 12 twelve months have you received any money from any of the following sources? i
a. Business, profession or other self-employment • · Yes · • No i
b. Rent payments, interest or dividends • · Yes · · No
c. Pensions, annuities or life insurance payments • yf es • • No Q
cl. Disability or workers compensation payments · • Yes · · No g
e. Gifts or inheritances · • Yes • • No
f. Any other sources • • Yes · · No i
If the answer to any of the above is “YES" describe each source of money and state the amount
received AND what you expect yo? will continue to receive.
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. Case 1:07-cv-00845—Gl\/IS Document 1 Filed 12/26/2007 Page 2 of 3 ·· ‘
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AO 240 Reverse (Rev. lll,/03i a
DELAWAKE {Env. QUE] . .
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4. Do you have any cash or checking or savings accounts? * • Yes · No n
If "Yes" state the total amount $ ' ‘ l
5. Do you own any-real estate, stocks, bonds, securities, other financial instruments, automobiles or other ·
_ valuable property? · l ‘ / {
• • Yes • No ‘
If "Yes" describe the property and state its value.
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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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I declare under penalty of perjury that the above infomation is true and correct. `
/\/0¢#»a?é?’° @2 Q .£/
DATE — SIGNATURE OF APPLICANT -
NOTE TU PRISONER: A Prisoner seeking to proceed without prepayment of {ees shall submit an afiidavit
stating all assets. In addition, a prisoner must attach a statement certified by the appropriate institutional
officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts.
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.
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Case 1:07-cv-00845—G1|\/IS Document 1 Filed 12/26/2007 Page 3 013
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Case 1:07-cv-00845-G|\/IS Document 1-2 Filed 12/26/2007 Page 1 of 1
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RESIDENT HISTORY REPORT Page 1 0f 1
HRYCI
11/26/07 08:29
str 007 / 01=·R JNM
SBI : 233532
Resident Name : GRUWELL, JEFFREY
Time Frame : 05/04/2007 17:37 - 11/26/2007 08:29
Date Time Type ST OPR Receipt # Amount Balance
05/04/2007 17:37 Intake 5 GGP E21491 0.22 0.22
05/16/2007 05:49 Order 2 WLI-I 13168365 0.13 0.09
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Case 1:07-cv-00845-GMS

Document 1

Filed 12/26/2007

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Case 1:07-cv-00845-GMS

Document 1

Filed 12/26/2007

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Case 1:07-cv-00845-GMS

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Filed 12/26/2007

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Case 1:07-cv-00845-GMS

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