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

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DEC—O¢l-2007 TUE 11130 HH ME SHFETY/COHPLiHllCE Ftiil NO. 7177035291 P· Ul
` UNITED STATES COURT OF APPEALS i
E FOR TI-IE THIRD JUDICIAL CIRCUIT _
Dennis Shipman, _1' .
Plaintiff-appellant, Pre Se District Court Docket
Civil Case No.: 07-CV-00687
I Circuit Court Docket
. vs.
The State of Delaware; Delaware State Police;
Corporal Vincent Tct·r:.n¤V£t; irtrliyiductlly and in hir ojjicinl capacity;
Trooper John Doe, individually-end. in his officftrl t·epc.·cfry.· Reynolds Towing
DeIendatit(s)-appelleetsl I .
MOTION T0 PROCIBEZD IN FORMA PA UPERIS I request permission to commence
an action against the defenclamt-appellee named above without the payment of fees. costs
or security. A proposed complaint is transmitted herewith. In support of this motion I
have attachecl the following:
1. Aflidavit n supplant nf Request to Proceed in Forrrm Prrtrperis relating to my inability
to pay cost. · d fees. \\
Date: December , 0
Si gnetute: i s. i
PTint Name; Dennis Shipman i` I
I Address: 231-27 Merrick Boulevard
City, State, Zip: Laurelton, New York, USA l 1413-2tl I
Telephone: 347-251-61-I0 p
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AFFIDAVIT SUPPORT OF MOTION TO PROCEED IN FORMA PAUPERIS
I further swear that the responses which lhave made to questions and instructions below
relating to my ability to pay the cost of proceeding in this action are ttue.
l. An: you presently employed? Yes No x
a. lf the answer is yes, state the amount of your salary or wages per month, and give the
name and address of your employer.
1:. If the answer is no, state the date of last employment and the amount of the salary and
wages per month which you received D7»'3l!2005
2. Have you received within the past twelve months any money from any of the i`oliowit1g‘
sources?
a. Business, profession or form of self-employment? Yes No >t
b. Rent payments, interest or dividends? Yes No it
C. Pensions, annuities or life insurance -payrnents‘? Yes No it ·
cl. Gifts or inheritance? Yes No x
e. Any other sources? "t' es x No `
IF the answer to any of the above is yes, describe each source of money and state the _
amount received form each during the past twelve months. FEMA (Please see attached]
3. Do you own any cash, or do you have money in checking or savings account? Yes
No it 11* the answer is yes, state the total value ot" the items owned.
4-. Do you own any real estate, stocks, bonds, notes. automobiles, or other valuable
, property (excluding ordinary household furnishings and clothing)? Yes No it
If the answer is yes describe the property and state its approximate value.
5- List the persons who are dependent upon you for support, state your relationship to
those persons, and indicate how much you contribute toward their support. NJA
lhav rEui:l·at1tl subscribed tothe above and swear, under oath, that the information is true
ttndcorrect p stunt! that a False staternentor answer to any question in this affidavit
will su j ct ‘ topo al ties for perjury. ` y
‘ Den TS-} ipman being tirst duly sworn under oath, presents thar he
ha ihed to the above add states that the information herein is true and 1
con K p
SUBSCRIBED ND SWORN TO before me this
3.td.d=·y ef 2aat
Notary Public or orherperzron
artrhprfzetf na administer on oath I
SEAL Notary Pihlliltiieo ilsieknlixlv ew York Y
I es~tlE‘§s?tlt"£%%‘ii’é2ttt I
Commission Expires August tel/EOE?

Case 1:07-cv-00687-GMS

Document 14

Filed 12/18/2007

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Case 1:07-cv-00687-GMS

Document 14

Filed 12/18/2007

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