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

Case 1 :07-cv-00641-GMS Document 1 Filed 10/16/2007 1 1 Page 1 of 2
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AO £41J(Rev. 1Uj I5) 5
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untrue sswrus mstrmcr couur OCT *6 ZOO?
DISTRICT OF DELAWARE l
U.S. [HSTHICT COURT l
DISTFHCT OF DELAWARE Q »
NINA SHAHIN, Plaintiff """`
Piamair APPLXCATEGN TG ?ROCEED
V. `WITHGUT PREEAYMENT GF 1
smarts or DELAWARE m___ FEES AND AFFIBAVIT
Defendant(s)
N CASE NUMBER; Q ? _p_ G A 1
L Nina Shahin [ Plainti f f declare that 1 am the (check appropriate box)
5 ° Betitioner/Plaintii’t`/lxflovaiit M f ° ° Other
in the above—emitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am tunable to pay the costs of these proceedings and that l am entitled to the relief
sought in the complaint/petition/inotion.
lu support of this application, l answer the following questions under penalty of periury:
l. Are you currently mcarcerated? ° Wes LW °No (lf "No" go to Question 2)
lf "YES" state the place of your incarceration _
Inmate Identification Number {Required): y y__ i
Are you employed at the institution? Do you receive any payment from the institution?
Altach a iedger sheet from the institution o[ vour incarceration showing at Feast the gust six months
rrayimctions
21 Are you currently employed? ° °`Yes No
a. lf 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. If 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. cg/Lf/’
3. in the past l2 twelve months have you received any money from any ofthe following sources? if @@3 Hi
a. Business, profession or other self-employment • ·· Yes @ · No
b1 Rent payments, interest or dividends ¤ • Yes @· No wg <
c. Pensions, annuities or life insurance payments • · Yes (E`? No I _
d. Disabiiity or workers compeusauon payments • · Yes El- No are
e. Gifts or inheritances • · Yes ®• No
f1 Any other sources · · Yes @l· No
lf 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-00641—G|\/IS Document 1 Filed 10/16/2007 Page 2 of 2
AO 240 Reverse (Rev. 20/03)
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4. Do you have any cash or checking or savings accounts? @· Yes · ·=· No G A {
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It "Yes" state the total amount $ ` i eo ~ Q p ` Q2
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other pt {
_ _ valuable property? _ - — ·-
CUM ww, Cl. ‘·{‘*$-j'**~*»i»» "Yes "N0 Oéjgd
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bws. { = *·j_g·· Gy dg%ib€ the property and state its value. @3* G/QE
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-.
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{declare under penalty ofperjury that the above information is true and correct.
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{Q ig, aw? le ~ .
D TE SIGNATURE OF APPLICANT
NOTE T0 PRISUNER: 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 yourinstitutional accounts.
It you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.

Case 1:07-cv-00641-GMS

Document 1

Filed 10/16/2007

Page 1 of 2

Case 1:07-cv-00641-GMS

Document 1

Filed 10/16/2007

Page 2 of 2