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

Case 1 :07-c®<‘§5F@CT"Q Al`)-pcument 1 Filed 08/20/2007 Page 1 of 2
A0240(R¤;. ltlr'03) 5;
` A P
UNITED STATES DISTRICT COURT Eze
Gi A1 ay and through 17
her parents and next friends
William and Maureen Anello iii
362 Alba Court
West Grove, PA 19390
Chester County, Pennsylvania _.
Piajmm APPLICATION TO PROCEED
. 1; WITHOUT PREPAYMENT OF
v' FEES AND AFFIDAVIT
Indian River School District
Serve Om CASE NUMBER O T ·- 5 O 3
Susan S. Bunting (officially)
31 Hoosier St.
Selbyville, DE 19975
Sussex County, Delaware
and 1
Susan S. Bunting (officially)
Superintendent of Schools
Indian River School District
Defendant(s)
I, Mamecn Anello declare that I am the Petitioner/Plain1jff7Movant in the above—entit1ed proceeding;
that in support of my request to proceed without prepayment of fees or costs under 28 USC §I9I5, 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/petition/motion. »
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? No (If "N0" go to Question 2)
If "YES" state the place of your incarceration _
Inmate Identitication Number (Required): _
Are you employed at the institution? Do you receive any payment hom the institution? _
Attach a ledzer sheet Qom the institution oi vour incarceration showing at least the past suc mont/1s'
transactions
I 2. Are you currently employed? _l§lg
a. Ifthe 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-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 hom any ofthe following sources?

Case 1 :07-cv-00508—Gl\/IS Document 1 Filed 08/20/2007 Page 2 of 2
a. Business, profession or other self-employment • - Yes ·X· No
b. Rent payments, interest or dividends • · Yes ·X· No
c . Pensions, annuities or life insurance payments · · Yes ·X· No
d. Disability or workers compensation payments ·X· Yes ·· No
e. Gifts or inheritances - · • Yes ·X· No
E Any other sources • • Yes ·X· 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.
SSDI $1,815.00 per month till January 2008
4, Do you have any cash or checking or savings accounts? X Y - ·N0
- --· ·- es
If "Yes" state the total amount S 200.00
5. Do you own any real estate, stocks, bonds, securities, other izinancial instruments, automobiles or
other valuable property? -X— Yes — - No
If “Yes" describe the property and state its value.
Primary residence valued at $ 379,000.00
Please see Bankruptcy No. 0741897 Eastern District of Pennsylvania
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.
Parent of G = A1 — 12 year old daughter 100%
Parent of A v A —— 9 year old son 100%
7. I declare under penalty of perjury that the above information is true and correct.
E?/tééf? . hléfgig gl ( %
DA TURE ICANT
NOTE TO PRISONERL A Prisoner seeking to proceed without prepayment of fees shall submit an ailidavit stating all assets.
In addition, a prisoner must attach a statement certified by the appropriate institutional oiiicer 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-00508-GMS

Document 1

Filed 08/20/2007

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Case 1:07-cv-00508-GMS

Document 1

Filed 08/20/2007

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