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

Case 1 :08-cv-00490-JJF Document 1 Filed 08/06/2008 Page 1 of 2
AO 240 (Rev. 10/03)
DELAV/ARE_(Ee;_uL
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
MONTY C PEPPER
Plaintiff, APPLICATION TO PROCEED
v. WITHOUT PREPAYMENT OF
FEES AND AFFIDAVIT
WARDON PHELPS &State od Delaware
Defendant(s) CASE NUMBER; '“ 0 8 °` 4 9 O N _
I, MONTY PEPPER declare that I am the (check appropriate box) . . A p W . .
' ‘ ` . , 4 I
E Petitioner/Plaintiff/l\/Iovant I:] Other `
in the above-entitled proceeding; that in support of my request to proceed · itho t pr£H£ym$t2cIIOH2es r
costs under 28 USC §19l5, I declare that I am unable to pay the costs of t ~ e p ceedings and that I
entitled to the relief sought in the complaint/petition/motion. U_S_ D'S·mE5~fCOuRT
DISTRICT OF DE WAR
In support of this application, I answer the following questions under penalty of perjury:
l. Are you currently incarcerated? IZ Yes I;] No (If "No" go to Question 2)
If "YES" state the place of your incarceration DCC 1 181 Paddock re Smyrna De 19977
Inmate Identification Number (Required): 156920
Are you employed at the institution? Np Do you receive any payment from the institution? No
Attack a ledger sheet form the institution ot your incarceration showing. at least the gast six
months ’
transactions
2. Are you currently employed? III Yes IZ No
a. If the answer is "YES" state the amount of your take-home salary or wages and pay
period 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. 2004
3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employment [I Yes E No
b. Rent payments, interest or dividends EI Yes IZ No
c. Pensions, annuiticx or life insurance payments EI Yes E No
d. Disability or workers compensation payments III Yes E No
e. Gifts or inheritances E Yes III No
f Any other sources I:] Yes E 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. money form mother and father to get
supplies to live

Case 1 :08-cv-00490-JJF Document 1 Filed 08/06/2008 Page 2 of 2
AO 240 (Rev. 10/03)
DELAWARE (Rev. 4/05)
4, D0 you have any cash or checking or saving accounts? [I Yes IXI No
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles
or other valuable property? III Yes IZ 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.
Son Matthew Pepper none .
I declare under penalty of perjury that the above information is true and correct.
L; \3. ZOOK k4
DATE L- 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 accotmt.

Case 1:08-cv-00490-JJF

Document 1

Filed 08/06/2008

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Case 1:08-cv-00490-JJF

Document 1

Filed 08/06/2008

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