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

Case 1 :07—cv—00687-GI\/IS Document 1 Filed 11/01 /2007 Page 1 of 2
UNITED STATES DISTRICT COURT
District of Delaware
mx { ·— E5 T
Dennis Shipman,
Plaintiii Pm Se Civil Case No.: 07-CV-
vs. Civil Rights Complaint
Pursuant to
42 USC § 1983
The State of Delaware; Delaware State Police;
Corporal Nicholas Terranova, individualbr and in his ajficial capacity;
Trooper John Doe, individually and in his official capacity; Reynolds Towing
Defendant(s)
MOTION TO PROCEED IN FORMA PAUPERIS I request permission to commence
an action against the defendant named above without the payment of fees, costs or security.
Aproposed complaint is transmitted herewith. In support of this motion I have attached the
following:
1. Affidavit in support of Request to Proceed in Forma Pauperis relating to my inability to
pay costs · l .
Date; Septe ·
Signature: ___.
Print Name is Shipman
Address: 231-27 Merrick Boulevard
City, State, Zip: Laurelton, New York, USA 11413-2111
Telephone: 347 -25 1 -6 140 p
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Case 1 :07—cv—00687-GI\/IS Document 1 Filed 11/01 /2007 Page 2 of 2
AFFIDAVIT IN SUPPORT OF MOTION TO PROCEED IN FORNIA PAUPERIS
I further swear that the responses which I have made to questions and instructions below
relating to my ability to pay the cost of proceeding in this action are true.
1. Are you presently employed? Yes No x
a. If the answer is yes, state the amount of your salary or wages per month, and give the
name and address of your employer.
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 07/31/2005
2. Have you received within the past twelve months any money from any ofthe following
sources?
a. Business, profession or form of self-employment? Yes No x
b. Rent payments, interest or dividends? Yes No x
C. Pensions, annuities or life insurance payments? Yes No x
d. Gifts or inheritance? Yes No x
e. Any other sources? Yes 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 x If the answer is yes, state the total value of 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 x
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. N/A
I have subscribed to the above and swear, under oath, that the infomration is true
and c ect, I understand that a false statement or answer to any question in this affidavit
will e to penalties for perjury.
Dennis Shipman being first duly sworn under oath, presents that he
has read and subscribed to the above add states that the information herein is true and
correct.
SUQQPS CRIBED AND SWORN TO before me this
\ day of RB 2007
§ is
Notary Public or other person
authorized to administer an oath {;p,Rr;)L||qE LQLLEY
NOTARY PUBLIC
SEAL STATE OF DELAWARE
My Commission Expires Apnl 15, 2008

Case 1:07-cv-00687-GMS

Document 1

Filed 11/01/2007

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Case 1:07-cv-00687-GMS

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