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

Case 1 :07-cv-00757-SLR Document 7 Filed O1/28/2008 ~;~···r,;:rrj;"·"r*w"i
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UNITED STATES DISTRICT COURT I " at
- DISTRICT OF DELAWARE ° I
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Plaintiff APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
EE gg _ gi; Q, L FEES AND AFFIDAVIT
Defendant(s)
` CASE NUMBER: 1; (ji}- QV-- '}_·§?- ‘
I, gg (.>QQéi—£ Qcééd gg A MA/ggg [ij; declare that I am the (check appropriate box)
M Petitioner/Plaintiff/Movant El Other
in the above-entitled proceeding; that in support of 1ny 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 and that I am entitled to the relief
t sought in the complaint/petitioii/motion. . ‘
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? M Yes E No (If "No" go to Question 2) pk '._?£m,?_
If "YES" state the place of your incarceration ¥Q@ ( 0 Eggggjg. Sgggj Cgéggg §“Ke'< M
Inmate Identification Number (Required): [{1;- Q [Q
Areyou employed at the institution? MQ Do you receive any payment from the institution? gf}
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast six nionths’
transactions
2. Are you currently employed? El Yes A M No
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.
3. In the past 12 twelve months have you received any money from any of the following sources? I
a. Business, profession or other seltlemployment III Yes ii No
b. Rent payments, interest or dividends D Yes IH? No
e. Pensions, annuities or life insurance payments Ei Yes l2' No
d. Disability or workers compensation payments El Yes IZ No
e. Gifts or inheritances EI Yes W No
f. Any other sources Yes U No
If the answer to any of the above is "YES" describe each source of money and state the amount .
i received AND what you expect you will continue to receive.

Case 1:07-cv-00757-SLR Document 7 Filed O1/28/2008 Page 2 of 3
Jaw _
, ? A0 240 Reverse (Rev. 10/03) I _ I I I
DELAWARE Rev. 4/05 . · ‘ Z {
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4. Do you have any cash or checking or savings accounts'? El Yes E No
lf "Yes" state the total amount $ ( 2 i
5 . Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other i
valuable property? E
El Yes ar No .
lf "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.
/1/ml/E ééfeese /51 1/1/ jam ga.iyy@ #’?£j§c®/tf ,
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I declare under penalty of perjury that the above information is true and correct.
1 **2 2+2wvB W J K/¢//»?4°#»% y
DATE I SIGNATURE OF APPLICANT · E
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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 i
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.

Case- 1-:07-cx}-00757-SLR 7gQ Eiled O1/28/2003 Page 3 of 3
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Case 1:07-cv-00757-SLR

Document 7

Filed 01/28/2008

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Case 1:07-cv-00757-SLR

Document 7

Filed 01/28/2008

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Case 1:07-cv-00757-SLR

Document 7

Filed 01/28/2008

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