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

Case 1 LDOcument 1-2 Filed 10/22/2007 Page 1 of 2
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DISTRICT OF DELAWARE {iq},
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riaimirr APPLICATION TO
V. WITHOUT PREPAYMENT OF
Nb UBS 5 O KM" tsl Gi it FEES AND AFFIDAVIT
Defendant(s)
` cass NUMBER; 0 T — 3 6 2 -
I, A \"\’“€> |\l¤ C, Q {Q N O lg declare that I am the (check appropriate box)
IE! Petitioner/Plaintiff/Movant Ci 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 I am unable to pay the costs of these proceedings and thatl am entitled to the relief
sought in the complaint/petitiorn’motion. .
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? KJ Yes IE/No (lf "No" go to Question 2)
If "YES" state the place of your incarceration `
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet jgorn the institution of your incarceration showing at least the past suc months ’
· transactions `
l 2. U Are you currently employed? [2/ Yes H E No - __“_ ,7/Q Od OO
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a. If the answer is "YES" state the amount of your lZE§;hOII'1€ salary or wages and p period a p
and give the Elaine and address f your employer i _P 1 \"_i"’\@g·__\l`_*'
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b. lf the answer is "NO" state the date of your last employment, the amount of y ur takethome °
_ - _ salary or wages and_pay periocland the narne and address of your last .e1_1_*rployerr`P _ " _ t ~
3. In the past I2 twelve months have you receivediany moneyifrom any of thefollowiné sources? » - l _ A- _. -
a. Business, profession or other self-employment El Yes l I1!/No
b. Rent payments, interest or dividends D Yes in} N0
c. Pensions, annuities or life insurance payments El Yes B?} No
d. Disability or workers compensation payments E1 Yes {3/ No
p e. Gifts or inheritances 1:1 Yes ?No
f. Any other sources _ El Yes No
If the answer to any of the 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-00662-Gl\/IS Document 1-2 _ Filed 10/22/2007 Page 2 of 2
A0 240 Reverse [Rev. I0/0]) n
DELAWARE [Rev. 4/D5`!
4. Do you have any cash or checking or savings accounts'? E1 Yes {No
lf "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
El Yes {No . _
lf "Yes" describe the property and state its value.
n- 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 it` applicable. ·
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I declare under penalty of perjury that the above information is true and correct. _
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e DATE SIGNATURE OF APPLICANT l
NOTE TO PRISONER: i A Prisoner seeking to proceed without prepayment of fees shall submit an
affidavit stating all assets. Inaddition, 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.

Case 1:07-cv-00662-GMS

Document 1-2

Filed 10/22/2007

Page 1 of 2

Case 1:07-cv-00662-GMS

Document 1-2

Filed 10/22/2007

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