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

Case 1 :07-cv-00669-JJF Document 1 Filed 10/24/2007 Page 1 of 3
I T · n' AO 240(Rcv. IOfD3)
DELAWARE Rev. 4/05)
. O R \ N UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
c A cm 5134/ `M
Piaamrr APPLICATION TO PROCEED
V. . l WITHOUT PREPAYMENT OF
jfj fe 0 pg p6£Q’*2//ff"? 8 A! FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER: O 7 _ 6 6 9
I, gg?-;”* scf A declare that I am the (check appropriate box)
EX Petitioner/Plaintiff/Movant E Other
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 l am unable to pay the costs of these proceedings and that l am entitled to the relief
sought in the complaint/petition/motion. I
In support of this application, l answer the following questions under penalty of perjury: E
C9 ag:
l. Are you currently incarcerated? E Yes me (lf "No" go to Question 2) 2
gs
If "Y`ES" state the place of your incarceration `
:1: ‘;=;E?·¤
_ Inmate Identification Number (Required): 26 73f/ /
....
Areyou employed at the institution?/VCV Do you receive any payment from the institution? In
Attach a ledger sheet Qorn the institution of your incarceration showing at least the past six months '
transactions
2. Are you currently employed? Q/Yes I] 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. r5i°<:0·*g'°’#“ T
l aan/; on _4&w·‘ 332·lnLl‘{ fj, Eg?/}°}€ y li 9 72¢’
b. lf the answer is "NO" state the date of your last empmgnent, the amount orfyour take-home
I 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 a11y money from any ofthe following sources?
a. Business, profession or other self-employment El Yes El/No
b. Rent payments, interest or dividends El Yes EF/No
c. Pensions, annuities or life insurance payments El Yes I3/No
d. Disability or workers compensation payments El Yes E1/No
e. Gifts or inheritances El Yes B"No
f Any other sources El Yes EVNIS
lf 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-00669-JJF Document 1 Filed 10/24/2007 Page 2 of 3
I ¢’ 2 ; a ...,.,
AO 240 Reverse (Rev. IUIO3) E LW"-
DELAWARE lRev. 4/D5!
4. Do you have any cash or checking or savings accounts? El4es El No
If"Yes" state the total amount EB "" C; C?] 5
5 . Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
Mes 1:1 No .
If "Yes" describe the property and state its value.
raw//v2:»c¢;e.. x gg. .:»·¤’¢’, 372 ··"
j Thcecfe -— —Qg>c>0, 60 L/_p£_J颣f Z-M E); ..Q/¤¢’
{ Qc.?/' ‘T' *2O‘°°°· "" ,4/;>»#2¢.-6.
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. ·
(9 7% g. MG7744.
I declare under penalty of perjury that the above information is true and correct.
” 07 :2
DATE SIGNATURE OP APPLICANT
NOTE TO PRISONER: I 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. If you have multiple accounts, perhaps because you have been in multiple
institutions, attach one certified statement of each account.

0 Case 1 :07-cv-00669-JJF Document 1 Filed 10/24/2007 Page 3 0f 3
:3 " \
Filmin 0 0 _- _
`i:Heu0?JQ1_i;j u - _ _0;_’ _ __ _1 " 7 I 1-li. ..·. 0 in " _ _` _ _ _ V
H1e~=I;·*·-mn113¥·Luuw nf ·- . n:zi?1}e10:a1w&r¢.
I1j·’II11·I1§r{E»]“ E·I!·¥¢.=m· €TZ:nss1.Em [I]§ant r _Si1ss¤a;0-E7n0u&§gr
CIVIL I¤·.l§51*UEITEl£}N —
_*F‘¤;%@$0.mFe¤1¢—=@i.*€£%wm,¤?!E»?=Q&;*%#i#r#é.¤¢ _1.1ee 0 e1/e .0 ..». 0 .0 ¤e‘_¤f·¤.¤¤¤¢¤¤L**@EE 0 .‘e *···‘ *
gggl-’%;'IEI11'H ‘e¤»c2*1·H ;.¤fZ5>E_.*`ST$·.RI?£ mcc11=·0m~1 0 ·
3.2;-1- ;¢0e11*g;»~¤z1:€·0L1xiva· . . 2:15 E=:¤.;01:.11 Dupmu.1; §’-§`:L§1.·mey _
..2l 1.. 0. ` .... ' _. 0 00 0 ‘ · · · I U N'!;u[E · ‘
me warm pu, :23 %`S‘*3m:i¤n fm?
0 0 0 0 0 ¥"·*‘&*e»»* 00 00 ?M:·E»¤x¤ 1
_ _ _w__ .._0_
J§e£·;ure PEHII £=£e01r1ih§r¤·, C¤:.~111m.ié+en0i<5Ea-env mf ·l;!€:=ur1;`.0 ‘ l U M ° l 1
wich H¤*T·I¤$xm Liv, eemimrleglegzrly the ef peQgme¤1·¤.
-:111 ELJTITEVFATE. E10e¤c:x»§1i11;:TI03y*, E»1x3*’I'I€;¤;+I ie $;'%IéllU}1<*·§]- 0 ·*i‘r$#
t·#E~:J12·I;E»";*' PF4.’£Tl¢1E§¤1‘T ‘.’·%‘s1iRE?aES »:;’1¤;?1_j0e im be zar;11ec1L11.g0¤;30 me¤;1iz41:0:L·::m z·as¤¤:¤11 as
pmaeiémie 0
IE :35.0} ¤iT}F:1;>E;RH:1;·.
0;%; 00 00 0. » 0 0 0 0 ._.
10.32:::2. °'¤1§·`_E‘ll'E@!'1. {0 ·1r·:rL1:· .:;sue;1 Euuummssnunc; I'·.#I:11*j»· }5*¤I1[I. 011::].111;; j
my ( X 1 P1:.·1t1E¢ic+r¤¤;:r { K 3 R0·::sp¤·nd¢m { X } FEL: {X] {315:; Manager {wml Eilé] `

Case 1:07-cv-00669-JJF

Document 1

Filed 10/24/2007

Page 1 of 3

Case 1:07-cv-00669-JJF

Document 1

Filed 10/24/2007

Page 2 of 3

Case 1:07-cv-00669-JJF

Document 1

Filed 10/24/2007

Page 3 of 3