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

_,t· 1 _ Case 1 :07-cv-00656-JJF Document 1 Filed 10/19/2007 . Page 1 of 2 . ’
ra · A.O‘2i0(Rev.1D/D3) , i ’ I ` i
" *‘ DELAWARE gev. · , ‘ · · t _
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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‘,__ by Q-/Zig,}/_7 P Plaintiff ‘ APPLICATION TO PROCEED
QU ’ V6 , 1 P WITHOUT PREPAYMENT OF
Zzé.-CC4 /7 Qdm A 6*//£i»ZZ» FEES AND AFFIDAVIT
Defendant(s)
. *· CASE NUMBER:
45* /2 i r · '” s A
I, ‘ ff declare that I am the (check appropriate box)
° ° Petitioner ovant ° ° Other ,.,, 0 7 - B 5 B U
in the ab ove-entitled proceeding; that iu support of my request to proceed without prey; gg ·.g_ __g c s I d ef 1.,.. ,
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings a.nd hat I am o@i elief
sought in the complaint/petitionfmotion. "·" · :·· ‘·P‘ -
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P In support of this application, I answer the following questions under penalty of peij 1 I
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1. Are you currently incarcerated? dugg ° °No (If "No" go to Quest' igiici vg iqi
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A l If "YES" state the place of your incarceration / /Z r ·’ / U//#7, /
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, Inmate Identilication Number (Required):
I Are you employed at the institution? Agé Do you receive any payment from the institution? é l
l Attach a ledger sheet Qorn the institution of your incarceration showing at least the gas! six months '
transactions I A
2. Are you currently employed? ° ° Yes 4%-
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. lf the answer is "NO" state the date of your last employment, the amount of your takeeh-ome _ p
salary or wages and pay period and the name and address of your last employer. 4}/1./4r J Aé
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3. , In the past l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employ1nent * • Yes 5%
b. Rent payments, interest or dividends • • Yes ·b/{2
c. Pensions, annuities or life insurance payments • • Yes · o
d. Disability or workers compensation payments · • Yes ·°‘·’No `
e. Gifts orinheritances • • Yes we
f. Any other sources · • Yes · o I
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.

A Case 1 :07-cv-00656-JJF Document 1 Filed 10/19/2007 Page 2 of 2
` AO 24U Reverse (Rev. 10/03) -
DELAWARE Env, MDE · ` .
l 4. Do you have any cash or checking or savings counts? • • Yes •%»
If "Yes" state the total amount $ i ‘
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
_ valuable property? ‘ .
° • Yes ·VN€`
If "Yes" describe the property and state its value.
6. I 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.
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_ I declare under penalty of perjury that the above information is mi and correct.
.z¤·/sé 09 i
DATE - SIGNATURE OF APPLICANT .
t NOTE T0 PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an affidavit
A 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.

. Case 1:07-cv-00656-JJF Document 1-2 Filed 10/19/2007 Page 1 0f 1
RESIDENT HISTORY REPORT V l ' ‘ Page 1 cnf 1
Haze:
00/31/07 10 1B
ST 007 / 0212 saw
SE1 1 191247
Resident Name 1 EVANS JR., AUGUSTUS H.
Time Frame 1 11/1a/zoos 14:51 - 08/31/2007 10 1B
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12/18/2006 14:51 Intake 6 bsp F24372 0.00 0.00
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Case 1:07-cv-00656-JJF

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Filed 10/19/2007

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Case 1:07-cv-00656-JJF

Document 1

Filed 10/19/2007

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Case 1:07-cv-00656-JJF

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Filed 10/19/2007

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