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

Case 1 :07—cv—00452-GI\/IS · Document 1 Filed 07/20/2007 Page 1 of 2
* ` 7* 3 AO 240 (Rev. 10/CB)
DEI..·\WAREgRev. 4{052
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
Nina Shahin
Piaiaua APPLICATION T0 PROCEED
V. WITHOUT PREPAYMENT OF
State Of Delaware, D¤1D¤*¤ suns AND Auuimvrr
Defe11dant(s)
CASE NUMBER: O T ... A 5 2
I, Nina Shahin declare that I am the (check appropriate box)
® ° Petitioner/Plaintiff/L/Iovant ° ° Other U _ pp__ E
in the above-entitled proceeding; that iu support of my request to proceed without pre •i= _ .· i
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and it at I {1 ¤ entitled to the relief
sought in the complaint/petition/motion.
. . llla
In support of this application, Ianswer the following questions under penalty ofperi W? DlSTF1l@`l @OU" _
‘ ° Q ·· .· r..,.rr...
1. Are you currently mcarcerated? Yes °No (lf No go to • ’ BU §(.m_n.,£r[
If "YES" state the place of your incarceration
Inmate Identification Number (Required):
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 gast six rn0nths’
transactions
2. Are you currently employed? ° ° Yes G) No
a. lfthe answer is "YES" state the amount of your take-home salary or wages and pay peiiod a
and give the name and address of your employer.
b. Ifthe answer is "NO" state the date of your last employment, the amount of your take-ho e
salary or wages and pay period and the name and address of your last employer. Q /31995*
3. In the past 12 twelve months have you received any money irom any of the following sources? Q GQ OOO
a. Business, profession or other self—emp1oyment • • Yes @• No
b. Rent payments, interest or dividends • • Yes ®• No
c. Pensions, armuities or life insurance payments • • Yes @• No
d. Disability or workers compensation payments • • Yes ®• No
e. Gifts or inheritances • • Yes ®• No
f. Any other sources • • Yes O No
Ifthe answer to any ofthe above is "YES" describe each source of money and state the amotmt
received AND what you expect you will continue to receive.

Case 1 :07—cv—00452-GI\/IS Document 1 Filed 07/20/2007 Page 2 of 2
AO 240 Reverse (Rev. ‘l0_{C6)
DELAWARE£&v. 4:052
4. Do you have any cash or checking or savings accounts? @• Yes • •No K
_ sr · Q Q; . ‘ - LJE ( Q ,
H` "Yes" state the total amount $ Jl? C9 &M`c'0’ A
wknigll fg /. 0 O -— @621:..,
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, au obiles or other .
valuable prope ‘? _ GD
OM; anal;.) OJLQ, use ww vu9e~u··uL %,,Y€s @_N0
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 much you contribute to their support, OR state NONE if applicable.
¤sN0vi2/
I declare under penalty of peijury that the above information is true and correct.
rg /8/ .,2002 QN.
AT SIGNATURE OF APPLICANT
NOTE T0 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.