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

. . Case 1 :O7—cv-00541-JJF Document 1 Filed O9/10/2007 Page 1 of 2
AO 240 (Rev. IUID3) `
DELAWARE {Rev. ·1.'05[
..__ UNITED STATES DISTRICT COURT -
_ DISTRICT OF DELAWARE
I .
§"l~‘€Ly {2 fg L QQ ,;·\\
i rianarr APPLICATION TO PRO CEED
V. WITHOUT PREPAYMENT OF
`Tsm, #2; Qing` ~ Q_e;_·&-\asl—ev Eesvyqpyul FEES AND Arrrnavrr
Defendant(s)
` CASE NUMBER:
I, Q ;lQ,g,` L. 3% gg, FS , m declare that I am the (check appropriate box)
IH Petitioner/Plaintiff/Movant D Other · s
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintfpetition/motion. I
In support of this application, I answer the following questions under penalty of perjury:
r-3 Zhi
l. Are you currently incarcerated? El Yes E No (If "No" go to Question 2) §
m _-"'»*=\
F1 5:: Q
lf "YES" state the place of your incarceration fj iZi&*“’;,,_
ce
_ Inmate Identification Number (Required): E
Are you employed at the institution? Do you receive any payment Eom the institution‘?:t°
CD EE :4:
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Attach a ledger sheet Qom the institution of your incarceration showing at least the past six li2Jontlzs"'l
, transactions
2- Are you currently employed? H Yes D No
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. C. west nz Ir Out ‘¤\— can (,5%; \l*\r‘\·‘¥¢·1c.|Q»t\\»»—·r,¤.·t)i\`}
l b. If the answer is "NO" state tl1e date of your la st 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 12 twelve months have you received any money irom any ofthe following sources?
a. Business, profession or other self-employment El Yes ji! No
b. Rent payments, interest or dividends CI Yes LZ No
c. Pensions, annuities or life insurance payments U Yes JB No
d. Disability or workers compensation payments U Yes $.1 No
~ . e. Gifts or inheritances U Yes EIA No
p y, f Any other sources El Yes E No
Ifthe 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-00541-JJF Document 1 Filed O9/10/2007 Page 2 of 2
AO 'MD Reverse (Rev. l0.'li3)
DELAWARE {Rev, 4/D5! `
4. Do you have any cash or checking or savings accounts? lB/ Yes D No
If "Yes" state the total amount $ tit? C), rpt?
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
El Yes El'} No .
If "Yes" describe the property and state its value.
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. s
-2 L O L \\,\. {_- l.\¥l_/IL \•'\‘}L"L. 5 _
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I declare under penalty of perjury that the above information is true and correct.
i‘i gi iw l W 'T""”“
AT SIGNATURE OF APPLICANT ·
NOTE TO 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; If you have multiple accounts, perhaps because you have been in multiple
institutions, attach one certified statement of each account.

Case 1:07-cv-00541-JJF Document 1-2 Filed O9/10/2007 Page 1 of 1
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Case 1:07-cv-00541-JJF

Document 1

Filed 09/10/2007

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Case 1:07-cv-00541-JJF

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Filed 09/10/2007

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Case 1:07-cv-00541-JJF

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Filed 09/10/2007

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