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

Case 1:07-cv—00636-SLR Document 1 Filed 10/16/2007 Page 1 of 2
AO 240 (Rev ll),/(I3]
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UNITED STATES DISTRICT COUR’Ift"€rt‘-fi {it
DISTRICT OF DELAWARE Emi; GC? ig mq 8: Sl
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Plaintiff APPLICATION T0 PROCEED
V. WITHOUT PREPAYMENT OF
z ‘ I t r
Stale all D i: ~l)tl .§· or tt of Ci, tcl §»i7ia·./ FEES AND Arrrmrvrr
Defendant(s) ,
p . CASE NUMBER: 0 7 _ 6 3 6
I, E I i ·’ declare that l am the (check appropriate box)
Pctitioner/ ovant Other
in the above-entitled 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 in the petition/motion.
In support of this application, l answer the following questions under penalty of perjury;
1. Are you currently incarcerated? Yes E @ (If "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identification Number (Required): r
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet [rom the institution of your incarceration showing at least the past six mont/as ’
transactions
2. Are you currently employed? @ No .
fini p @5 5 ljrnie-at- @ fj wwe — Gift/ty Www-/rj BE
_a_ If rho answer ig "Y`ES" Stott; the amount of your tavlgiyliomgj/22aEr or wagjggnd pay pg `od a,. M/6
d` th rddessf uremloe..’»/VOE/O I `l·UQ~&,7f.l
·%“i§sff5€’$t§rff`of“£§€fadatet isiaiiii , J i e vita rupee.! rein i 7,,/’¥ZO3;rgi
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b. lf the answer rs "NO" state t g dye o your last employment, 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 l2 twelve mouths have you received any money from any of the following sources?
a. Business, profession or other self—employment Yes
b. Rent payments, interest or dividends ‘ Yes cp
c. Pensions, annuities or life insurance payments [ 7 f, ;I3§'po,,,%,@=Ts> No
d. Disability or workers compensation payments Yes
e. Gifts or inheritanees _ Yes
f. Any other sources E.,t,Lq_.q¤_ _ prgsirti/ZJ-e I faire 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. or

Case 1:07-cv—00636-SLR Document 1 Filed 10/16/2007 Page 2 of 2

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4. Do yOU l'l3V€ Ellly cash Of Cll€C` lllg O1' dVll'lgS HCCOUIHS? I a YES / ;/J
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It"'Yes" state the total amount Si 5,0 {W" 1%
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5. Do you own any real estate, stocks, bonds, secur1t1es, other tinancral instrurnents, automobtlgs or ot er
valuable property? _`
@5 No
If "Yes" describe the property and state its value. [ F) lit, jg/M 3/VIL/ix P} {/-16%
pu; lat $,500, oi:
6. List the persons who are dependent on you for support, state your relationship to eaejuperson ayi f »
indicate how niuch you contr®1te Loiheir suppeE§;OR st te NONE if applieabgg 1 {
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I declare under penalty of perj my that the above ` formation is true aud correct.
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DATE SIGNATII OF APPLICANT
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NOTE TO 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
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-00636-SLR

Document 1

Filed 10/16/2007

Page 1 of 2

Case 1:07-cv-00636-SLR

Document 1

Filed 10/16/2007

Page 2 of 2