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

_ . Case 1 :07-cv-OO768—G|\/IS Document 1 - Filed 11/27/2007 Page 1 of 2 i
. V ‘ AO 2·t0iRev.10iG3) U ` l
, DELAWARE {Rev. 4{USI ‘ · _ ___L_!____— | _ L
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
‘ . i
_ riatattrr APPLICATION TO PROCEED .
Q —-Q" WITHOUT PREPAYMENT OF l
K L ,-.-~ A FEES AND AFFIDAVIT l
Defendant(s) · _ . . i
ASE MB R: i
1 interest I C Wi
I, declare that I am the (check appropriate box) p 4
° ° Petitionerfl-‘laintiffflviovant ° ' Other ]
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under 1
28 USC §l9l5, Ideclare that I am unable to pay the costs of these proceedings an ¤· _ ·__·· r- _. 4,. _e .=_J- · · .- -. {
sought in the cornplaintfpetitionjmotion. F Q L E é i
‘ In support of this application, I answer the following questions under penalty of perj ; 'lt§(]\i Q1?
1. ' Are you currently incarcerated? E ° °No (If "No" go ·* .2. m.a.amsa s.rr i
® \ us. M SG , , { 1
‘ ‘ S T i': **1 ; “· ‘ . . · ·
If` "YES" state the place of Your incarceration vg Qt t l ; »~ ~ e- " ·· · ·· · " · ‘‘`‘‘‘ ‘ " t
Inmate Identification Number (Required); Q/Q i [ ( L
· Are you employed at thelinstitution? Do you receive any payment from the institution? l
I Attack a ledger sheet Quin the institution of your incarceration showing at least the gust six months ’
transactions
2. Are you currently employed? ° ° Yes `
a. If the answer is "YES" state the amount of your take-home salary or wages and pay period a I
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 yotu last employer.
3. In the past 12 twelve months have you received any money from any ofthe following sources?
a. Business, profession or other self-employment · · Yes • • •.
b. Rent payments, interest or dividends • • Yes
` c. Pensions, annuities or life insurance payments • • Yes @
d. Disability or workers compensation payments ` • • Yes · · No ,
e. Gifts or inheritances · · Yes
f. Any other sources • • Yes • • N
If the answer to any ofthe above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.

_. Case 1 :07-cv-00768—Gl\/IS Document 1 Filed 1 1/27/2007 Page 2 of 2_ _ "
AO 240 Reverse (Rev. 10,/ D3) 1
DELAWARE {Rev. QUE] I ·
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l 4. D0 you have any cash or checking or savings accounts? • • Yes l
If "Yes" state the total amount $ '
5. Do you own any realestate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? ‘
_ · · Yes ®
_ If "Yes" describe the property and state its value. U
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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.
Ideclare under penalty of pe ab · ` formation is true and correct. `
an { I I ln • u U
\ _.¢ ,/ "/" i
DAT Y . sronaruas or APPLIC i
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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 by the appropriate institutional ·
officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. l
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account. p
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Case 1:07-cv-00768-GMS

Document 1

Filed 11/27/2007

Page 1 of 2

Case 1:07-cv-00768-GMS

Document 1

Filed 11/27/2007

Page 2 of 2