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

_` _, Case 1 :07—cv—00683-Gl\/IS Document 1 Filed 10/29/2007 Page 1 of 2
· t l t. D
AO 240 (Rev. 10} 03)
DELAWARE Rev. 4 U5) l
2 9 QGC'?
UNITED STATES DISTRICT COURT
M DESTRECT OF DELAWARE _l
Dteittwrd le D bamag,
riaiaatr APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
(l~NL.St_ ’Il¤\M\a.$’ gftggi. (html OMGM6 FEES AND 3FFI])%VITr__
Defendant(s) "“ 7 _. 8
CASE NUMBER;
I, I)t€5&}L2»r§ § declare that I am the (check appropriate box)
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? ° °No (If "No" go to Question 2)
If "YES" state the place of your incarceration Ceyemswi mai
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution? xg
Attach tz ledger sheet from the institution o{ your incarceration showing at feast the post six mont/1s’
transactions
2. Are you currently employed? ° 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. lfthe answer is "NO" state the date of your last employment, the amount of your take-home
sala.ry or wages and pay period and the name and address of your last employer.
3. In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment · • Yes I . · · .
b. Rent payments, interest or dividends · · Yes -·¢!f§f!"
c. Pensions, annuities or life insurance payments • • Yes I _ -g,,s»
d. Disability or workers compensation payments · __-
e. Gifts or inheritances i f e I I
f. Any other sources ‘ • · Yes · ‘— = I
If the answer to any of the above is "YES" describe each source of money and state the amount
received ARE) what you expect you will continue to receive.
A - 4 _) i. - . r
DUGF (ff- `é‘:L*'*f¢'·fié’ 602/7 .j fr€¤

_ F Case 1:07—cv—00683-Gl\/IS Document 1 Filed 10/29/2007 Page 2 of 2
DELAWARE CORRECTIONAL CENTER
INMATE REQUEST FOR CERTIFIED TRUST FUND
ACCOUNT STATEMENT OF PRIOR SIX—MONTI—1 PERIOD
TO: Mrs. Tonya Smith
Support Services Manager DATE: i
Delaware Correctional Center
Smyrna, Delaware 19977
_ f »·— .-I _ .,
F ROM: ‘ 4 . · iz 8 %
Inmate Name (Please Print Name SBI #
‘\.
_ --— IHEREBY CERTIFY -—-
Pursuant to the Prison Litigation Reform Act, 28/U.S.C. 1915 (a)(2),
Effective April 26, 1996, I am requesting a certified Statement of my Institution Trust
Fund Account for the previous six-month period. Please forward same to me. A
Sigiiatute 1
(28 U.S.C. 1746 and 18 U.S.C.1621) ‘

Case 1:07-cv-00683-GMS

Document 1

Filed 10/29/2007

Page 1 of 2

Case 1:07-cv-00683-GMS

Document 1

Filed 10/29/2007

Page 2 of 2