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

Case 1 :08-cv-00102-SLR Document 1 Filed 02/15/2008 Page 1 of 2
I i AO TAD (Rev. IOIDB]
DELAWAREERW, 4/D5;
S I UNITED STATES DISTRICT COURT 1‘I
DISTRICT OF DELAWARE _r_
juttt FEB I5 Pli l= U5
K` ‘ I
rtamttrr APPLICATION TO PROCEED
ipict mc? n d Svluqlg/. [PO r—I* C0 r l3· WITHOUT PREPAYMENT OF
5. ti- · li I I-Occtf [Qi] "/‘l I FEES AND AFFIDAVIT
Defendant(s)
` CASE NUMBER: Q g ... 1 Q 2

Legg! it IQ (`C;i gg (j\i declare that l am the (check appropriate box)
gf Petitioner/Plaintiff/Movant El Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings and thatI 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:
l. Are you currently incarcerated? El Yes E No (If "No" go to Question 2)
If "YES" state the place of your incarceration O
r Inmate Identification Number (Required):
. Areyou employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet Qorn the institution of your incarceration showing at least the gast sib: months ’
transactions l
l 2. Are you currently employed? lj Yes E No
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 'YNO" 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 from any of the following sources? I
a. Business, profession or other self-employment IZ/YES U No
b. Rent payments, interest or dividends B/Yes El No
c. Pensions, annuities or life insurance payments EI Yes glide
d. Disability or workers compensation payments El Yes No
_ e. Gifts or inheritances El Yes @0
f. Any other sources d _ El Yes ' No
[fthe answer to any Of the abgve is "YES" describe each $01,1% of l'[[OI16}’ 3.Ild SICBEBIIIC HHIOUHI .\ H
received AND what you expect you will continue to receive.Dé’ F rica r Q, fpghjfdf rw tl · L/ $(6 ’
K- · ,' e. - L
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Case 1 :08-cv—00102-SLR Document 1 Filed 02/15/2008 Page 2 of 2
AO 240 Reverse (Rev. IOJDJ)
DELAWARE Rev. 4/U5!
4. Do you have any cash or checking or savings accounts? U Yes @40
If "Yes" state the total amount $
5 . Do you own any real estate, stocks, bonds, securities, other financial instruments, utornobiles or other
valuable property'? ""'
eg Cl No
If "Yes" describe the property and state its value. `-if
i I \ " ’ -—i és
QED S ul 0 fl
at 6. List the persons who are dependent on you for support, state your relationship to each person and
indi ate how much yo contribute be their support, OR st2;e NONE if applicable. I
clnlfl So rtkri <§><>-[ 53 Pre M ee
2;,* Ha F rl I
Q.1—l.¢O»ooil~c’r .
I declare under penalty of perjury that the above information is true and correct.
y l
J2- /e -0 8 5
e DATE SIGNA 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 1:08-cv-00102-SLR

Document 1

Filed 02/15/2008

Page 1 of 2

Case 1:08-cv-00102-SLR

Document 1

Filed 02/15/2008

Page 2 of 2