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

Case 1 :07-cv-00661-GMS Document 1-2 Filed 10/22/@12 A0 240 (P.ei=. wins)
DELAWARE Rev. 4.*05 . l
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
ié C/Gll‘-L l\l·*0l‘·i
Plaintiff APPLICATION TO PROCEED
V. g} _ WITHOUT PREPAYMENT OF
l Pr ll G ‘€/T' S To EES Fans AND Arrrnnvrr I
Defendan1;(s)
` CASE NUMBER: ,, n f
. _ { tr Y l
I, A K `R'0 IA C Cl l\LO Fr declare that I am the (check appropriate box) y
lE/ Petitioner/Plaintiffflyflovant 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 I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintfpetitiori/motion. L
In support of this application, I answer the following questions under penalty of perjury; Q 2
l. Are you currently incarcerated? Cl Yes @0 (If "No" go to Question 2)fg l
°U' "ri i
If "YES" state the place of your incarceration E. ‘ l
no m .---
*·
Inmate Identification Number (Required): W
. Areyou employed at the institution? Do you receive any payment from the institution?
Attach o ledger sheet Qorn the institution of your incarceration showing or feast the goat six months '
transactions - ` `
I 2. Are you currently employed? miss E1 No ,,
L lvSOOWN€2§`1/$00 °* 0 O
a. If the answer is "YES" state the amount of your take—home salary outrages and pay geriod a _
$ (bg and giye the name and address of your employer. §;§;3€»‘ A @(4- ii \l"\¢rr·'l'
2- OG Q<»1-at-·<¤7) l-<>O¤· G7-··¤‘i) wg ‘&.,\g~&a it terse,
b. If the answer is "NO" state the date of your last empl yment, the amount of your take-home _
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 any money from any of the following sources? O
a. Business, profession or other seltlemployment D Yes h [{1/ No
b. Rent payments, interest or dividends D Yes EV No
c. Pensions, annuities or life insurance payments U Yes 15) No
d. Disability or workers compensation payments El Yes @No
e. Gifts or inheritances El Yes S/No
f Any other sources _ III 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-00661-GMS Document 1-2 Filed 10/22/2007 Page 2 of 2
A0 240 Reverse (Rev. 10/O3)
DELAWARE lllev. 4/D5! "
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4. Do you have any cash or checking or savings accounts? U Yes Mio _
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other l
valuable property?
Ei Yes if No .
If "Yes" describe the property and state its value. l

. i
l 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. I .
E¤lC¤Uk}."‘“ my C}q¤i5lnT‘€’.»f` y
I l
a N G N €/ · . o j
I declare under penalty of perjury that the above information is true and correct.
W —* vv *07 @1%% §
· DATE SIGNATURE OF APPLICANT e l
NOTE ro PRISONER: - A Prisoner seeking to proceed without prepayment of fees shall submit an
aftidavit stating all assets. In- addition, a prisoner must attach a statement certified by the appropriate
institutional ofiicer 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-00661-GMS

Document 1-2

Filed 10/22/2007

Page 1 of 2

Case 1:07-cv-00661-GMS

Document 1-2

Filed 10/22/2007

Page 2 of 2