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

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DISTRICT OF DELAWARE ily
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. _ rnaitirr APPLICATION TO PROCEED
V. VHTHOUT PREPAYMENT OF
Lotwrrenca oil'; can ,r {Irene. _@;,tFl, .l.J1iiw`s:r/i FEES AND AFFIDAVIT y
Defendant(s) · - i
CASE NUMBER; O T " 5 2 8 i
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I, C"5 seep lg, I - 5 ;_·»;t~l·i;; declare that I am the (check appropriate box)
° ° Petitioner ovant ° ° Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under y
28 USC §1915, 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/petitiorr/motion. _
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In support of this application, I answer the following questions under penalty of perjury:
1. 1Are you currently incarcerated? _ I/;r_§s\ ° °No (If "No" go to Question 2)
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If "YES" state the place of your incarceration lgimwctrgi jg mg ( Q;g;§,1l;p,·m¤ ig;*;L,"l;HX·,‘gr3¤
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Inmate Identitication Number (Required):
Are you employed at theiinstitution? N0 Do you receive any payment from the institution? M @3 `
l Attach a ledger sheet Qom the institution of your incarceration showin at least the past six months '
transactions
2. I Are you currently employed? ° ° Yes
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. `
b. If the answer is "NO" state the date of your last employment, the amount of your take·horne
salary or wages and pay period and the name and address of your last employer.
3. In the past l2 twelve months have you received any money from any of the following sources?
a1 Business, profession or other seltiemployment • • Yes @0
b. Rent payments, interest or dividends • · Yes
c. Pensions, annuities or life insurance payments · • Yes
d. Disability or workers compensation payments • • Yes · ·
e. Gifts or inheritances ‘ • · No
f. Any other sources • • Yes @
If the 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-00528-SLR Document 1-2 Filed 08/31/2007 Page 2 of 2* I .
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DELAWAl7,E SE?. QUE} ·
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4. Do you have any cash or checking or savings accounts? - • • Yes • QQQ
If "Yes" state the total amount $ '
S. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other A
valuable property? ‘
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lf "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 rnuch you contribute to their support, OR state NONE if applicable.
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I declare under penalty of perjury that the above information is true and correct. `
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ATE - SI ATURE 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 certitied by the appropriate institutional
officer showing all receipts, expenditures, and balances duringthe 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-00528-SLR

Document 1-2

Filed 08/31/2007

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Case 1:07-cv-00528-SLR

Document 1-2

Filed 08/31/2007

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