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

Case 1 :O7—cv-00529-l\/I PT Document 1-2 Filed O9/O4/2007 Page 1 of 2 -
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Plaintiff APPLICATION TO PR€I
v._ wrrrrour PREPAYIN/I§NlTi§*_il’f
if fl l§,T§.‘l“I,§;g_tA flgl§l--A Hfgiilt { it $2 ZSZ'§·’tt‘§ FEES AND
Defendant(s) er. O _ shit?
CASE NUMBER: i" 7 2 9 ""`
L T“i?P& MU? fb LVM (3 Ec1;§_Q§ l>f2J.}‘ 'SEG declare that I am the (check appropriate box)
ig Petitioner! lflaintE’Movant El Other
in the above—e11titled proceeding; that in support of my request to proceed without prepayment of fees or costs under
23 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petitionfmotion.
ln support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? D Yes E No (lf "No" go to Question 2) I
If "YES" state the place of your incarceration '
K Inmate Identification Number (Required):
Areyou employed at the institution? Do you receive any payment from the institution?
· Attach a ledger sheet frgom the institution of vour incarceration showing at least the gust six months ’
transactions
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2. Are you currently employed? El Yes El No
a. lf the answer is "YES" state the amount of your take—home sal or w es r dpa · period a
and_give the na}me_and address o§y;our e ployer.Gf
-_ S~5CutrZIT>· ‘$¤?Ki¤’iZ@€3—2€{h_£lir6G2; ~-» il! It l· it KLV
b. Ifthe answer is "NO " state Exe diite of 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 I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment El Yes JH No
h. Rent payments, interest or dividends U Yes No
c. Pensions, annuities or life insurance payments El Yes pf No
d. Disability or workers compensation payments U Yes No
e. Gifts or inheritances fJ_ Yes No
f Any other sources __ _ _ { _ V A/i€(\Yes _ J _ q { _A_
· MMISKYM MMl·*téiEIl»l?S7Ul# LEE till;}/tffiij ·’{H,Lf BMI} #";illtlT`LL EA {Litt'?
If the answer to any ofthe above is "YES" describe eaclr source of money and state the amount ltlili-3 ELEIH Thi
received AND what you expect you will continue to receive. , >/grip; Lt LD ·

Case 1:O7—cv-00529-l\/IPT Document 1-2 Filed O9/O4/2007 Page 2 of 2
AO 240 Reverse (Rev. lD.'U3)
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4. Do you have any cash or checking or savings accounts'? Yes E1 No
lf "Yes" state the total amount $ _Q-
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? .
jg Yes E1 No
If "Yes" describe the property and state its value.
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6. List the persons who are dependent on you for support, state your relationship to each person and
indicate how rnuch you contribute to their support, OR state NONE if applicable.
pi __ · L-r "F ~— J #iU6%l+l`T€f€» p _ A _ ___ _, _
TK ll ,1 we A Trivieraeal 3/6.Afe Ou) Dsl wélareli, Friar U {:P@<{Q5
,;?>.zU M E" F0? f>M?>P0!£T, trltrlijt, BE (fo1u5§_ HTli_t:i~/
ry gas, {ZS AOLD F .-L liu (Ly CON‘nQ;ti {3 Ll T5 TQ (-t EIGL -il P/DCJEJ/i
l declare under penalty of perjuiy that the above information is true and correct.
il / "' { " 7 hmm) ofgam eiwl / Qfepmttil? AJ/MU tif.!}
DATE 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-00529-MPT

Document 1-2

Filed 09/04/2007

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Case 1:07-cv-00529-MPT

Document 1-2

Filed 09/04/2007

Page 2 of 2