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

Case 1 :07-cv-00644—Gl\/IS Document 1 Filed ·1 0/1 6/2007 Page 1 of 2
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° AO 240 (Rev. l.D,!€B) ______M__~___ 1 '
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DISTRICT QF DELAWARE 1 1
- U.S. DISTRICT COURT .
_ - DISTRICT OF DELAWARE _,___ -
NINA SHAHIN, Pla1r1tj.ff ‘ ‘
Plaintiit APPHCATIQN T0 ?ROCEED
V. WITHGUT PREPAYMENT GF l
STATE or DELAWARE FEES AND AEEEDAVIT
De{"endant(s) _. 1_ or _ ,
CASE NUMBER: " lf EJ 'j‘ A
{_ Nina Shahinl Plaintj. f f declare that l am the (check appropriate box)
@5} ° PetitionerfPlaintil?l`fMovant __ f § ° Other
in the aboveentitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §19l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought inthe complaint/petitionlmotion.
ln support of this application, I answer the following questions under penalty of perjury:
11 Are you currently incarcerated? ° Wes {E2 We Gl" "No" go to Question 2)
lf "YES" state the place of your incarceration · E
Inmate Identification Number (Required); i
Are you employed at the insutution? Do you receive any payment from the institution?
Attach rz ledger sheet {rom the institution 0[ your incarceration showing ot least the gas! six months '
transactions
21 Are you currently employed? ° ° Y es ® No
a. lfthe 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 take-hpme
salary or wages and pay period and the name and address of your last employer. Q// [ J
3. In the past I2 twelve months have you received any money from any ofthe following sources? Q SQ GCE?} wi
a. Business, profession or other self-employment · · Yes Q ¤ No
b. Rent payments, interest or dividends · · Yes @· No lim
c. Pensions, annuities or life insurance payments · ·· Yes Q- No i _` f =
d. Disability or workers compensation payments · • Yes (El- No ob eu
e. (Bins or inlreritances · · Yes (§l· No
1 tl Any other sources · · Yes _ {f}· No
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-00644—Gl\/IS Document 1 Filed 10/16/2007 Page 2 of 2
AO 240 Reverse {Rev. 10,*03)
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4. Do you have any cash or checking or savings accounts? @• -Yes • • No 0 ,1 A
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It`"Yes" state the total amount $ `J ·=* · »t·.»._, L T YO ( 3 MGML
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5. Do you own any real estate, stocks, bonds, securities, other financiai instmrnents, automobiles or other ty { fg
vaiuebie roperty? l ··
(QL, Omm;53 sm, €,,_ mCsn~_e.. forge . . YES .. . No . l. my; L
so 5 os? ‘ 12=uJ:> a,~.lm»L“¤`>°·—s t`l*~$i.»~’?5<> wit ’ . "
Visit? · **5 ·=v€s··mm the property and state its value. Qian Ga
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.
GJQ cio;
I declare under penalty ofpotjury that the above information is true and correct.
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D TE SIGNATURE OF APPLICANT
NOTE T0 HIISONER: A Prisoner seeking to proceed without prepayment of fees shan 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 yourinstitutional 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-00644-GMS

Document 1

Filed 10/16/2007

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Case 1:07-cv-00644-GMS

Document 1

Filed 10/16/2007

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