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

. _ Case 1 · — v-00642—G|\/IS Document 1 Filed 10/16/2007 Page 1 of 2
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2007 ~
OCT 1 6 UN@D STATES BESTRICT CGURT
DISTRICT GF DELAWARE 1
D15TP.1GT const
D?E]§1%1GT OF DELAWARE . 1
_ NA SHAHIN, Plaintiff '
siasiarr APPLECATIGN T0 ?RG€EED 1
. V. RVETHGUT PREPAYMENT QF .
aware or DELAWARE FEES AND AFFIDAVET
Defendant(s)
CASE NUMBER:
L Nina Shahiril Plaintiff declare diat I am the (check appropriate box) 1
@ ° Petitioner/Plaintiff/hlovaitt f ° ° Other
1
in the aboveentitled proceeding; that io support of my request ro proceed without prepayment of fees or costs under 1
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief 1
sought in the complaint/petitioafmotion. 1
1
In support of this application, I answer the following questions tmder mnalty of perjury: 1
hi .
i. Are you currently incarceratecl? ° °fes @5/ °No (lf "No“ go to Question 2) {
lf "Y`ES“ state the place ofyour incarceration :
i `
Inmate Identification Number (Required): ___
Are you employed at the iusotutiou? Do you receive any payment from the institution?
Attach rz ledger sheet [rom the institution oi your incarceration showing at least the gust six mom‘h.r'
transactions
2. Are you currently employed? ° °Yes ’ No
a. [fthe answer is "YES*' state the amount of your take-home salary or wages and pay period a 1
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-heme
salary or wages and pay period and the name and address of your last employer. gf ! x
3. ln the past 12 twelve months have you received any money from any ofthe following sources? gg Fié
a. Business, profession or other selfemployment · ·· Yes il · No gvga fl Wyhwij
· b. Rent payments, interest or dividends • • Yes <`él• No _ €@@
c. Pensions, annuities or life insurance payments · · Yes (§}• No { I *·
d. Disability or workers compensation payments · • Yes @• No {Zire
e, Gifts or iuhezitatices ·· ·¤ Yes (_§}·· No
f. Any other sources · · Yes @· No
if the answer toany ofthe above is "YES" describe each source of money and state the amount
received AND what you expect you will continue to receive.
L

. Case 1:07-cv-00642-GIVIS Document 1 Filed 10/16/2007 Page 2 of 2
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4. Do you have any cash or checking or savings accounts? G}- Yes ·· ·No
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,, ., $...0 . ¥;7'?U(g»tu:t@o»tcsfi}·.&~{Z~L“”"?j
lt` Yes state the total amount $ ~ ·*“ -—.o_, · F Lyin) .
M_/lf/g,t`:»l&. so, I
5. Do you own any realestate, stocks, bonds, securities, other financial instruments, automobiles or other ,2* / {
_ r N valuable roperty? _ _ , QR t ·· “' l
CUMR Mc Lk ‘~"~£·“rW¤l~ “`*" ' ° YGS ‘ ‘N¤ i
?A,M,€a ‘= i
·’ 2 "Yes" de ribe the property and state its value. _ a _ __ j sa. _ fl
rs- &w¤»%,ers all iw all
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6. List the persons who are dependent on you for support, state your relationship to each person and i
indicate how much you contribute to their support, OR state NONE if applicable.
all one
I declare under penalty of penjtny that the above information is true and correct,
L
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D TE SIGNATURE GF APPLXCANT
NOTE T0 PRISONER: 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.
lf you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.

Case 1:07-cv-00642-GMS

Document 1

Filed 10/16/2007

Page 1 of 2

Case 1:07-cv-00642-GMS

Document 1

Filed 10/16/2007

Page 2 of 2