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

Case 1 :08-cv-OOO73—G|\/IS Document 1 Filed O2/O4/2008 Page 1 of 2
I · AO 24D (Rev. 10/03) I
DELAWARESRev. 4L'05! , _ _ _ _ _ _ _ _
_ ` UNITED STATES DISTRICT COURT Q
DISTRICT OF DELAWARE
Plaintiff APPLICATION TO PROCEEI) {
V. WITHOUT PREPAYMENT :
FEES AND AFF IDAVIT t ‘
Defendant(s) _ . __ ·~»- O -· at i
CASE NUMBER: 8 T i
I, QOC;) lg Q {Q`; declare that I am the (check appropriateiittox)
M S
° ° Petitione /Movant ° ° Other In A iii l
in the above-entitled proceeding; that in support of my request to proceed vvithoht prepayment of fees or costs under I
28- USC §l9l5, I declare that I arn unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaintfpetitioii/motion. . . _ f
In support of this application, I answer the following questions under penalty oi` perjury: ·
1. Are you currently incarcerated? ° ° °No (lt "No" go to Question 2)
If "YES" state the place of your incarceration jgi Q gg]; {jug;. {gg QE Q bgggx Q mg E6?
· Inmate Identification Number (Required): Q QQ Q ';,l °`\ ij] gg g Q, . r __
Are you employed at the institution'? Do you receive any payment trom the institution?
Attach a ledger sheet from the institution at your incarceration showing at {east the gas! six months’
_ transactions __ p
2. Are you currently employed? ° °Yes ° No A A
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. ;
l b. If the answer is "NO" state the date of your last employment, the amount of your tke—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?
a. Business, profession or other self-employment • · Yes · · No
b. Rent paymentsy interest or dividends • · Yes · · No §
c. Pensions, annuities or life insurance payments · • es · · No ;
G Disability or workers compensation payments {E3 · • No
e. Gifts or inheritances ·`• Yes · • No {
f. Any other sources . · • Yes • · No j
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. j5_ 5 Q, Q Q; _ Q) O .
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Case 1:08-cv-OOO73—Gl\/IS Document 1 Filed O2/O4/2008 Page 2 of 2
AD 240 Reverse (Rev. 10,/ G3)
DELAWARE Rev. 4fU5t ·
4. Do you have any cash or checking or savings accounts? • • Yes
lf HWKCSH state the total amount S ¤
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5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other I
valuable property? I
. - _ _ O I I
lf "Yes" describe the property and state its value.
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6. List the persons who are dependent on you for support, state your relationship to each person and I
11 a 0 TDHC youconrtueo ensuppo sae iapptcare ll an i
~ idictehw, h t'bttth` n,ORttNONE`f i` bi. . I
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l declare under penalty of perjury that the above information is true and correct. - - · I I I
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. ‘ K E I
it I ` _. . I
DATE J SIGNATURE OF AP ICAN T
I
NOTE T0 PRISONER: A Prisoner seeking to proceed vvithout 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. I
. I

R- Tm ... N Wcee;T;6eie; T A · I
DELAWARE CORRE C T I ONAL CENTER
- ` SUPPORT SER EICES OFFICE
MEMORANDUM
S To.- FSP! A · UAH »e y ¢ A4 sB1#.- b{T7lp\Le
FROM: Stacy Shane, Support SeTvtL Secreta1{y =
RE: 6 Months Account Statemlnt
. A *
DATE.- 3g;-gg Qggw M Qqygjk
\?t3ji1fa are C£}E7{€S- of yotétgsttnmg acco%»tnt state%:r;1;r§;*gi€_§he months-of h he following indicates the average daill/balances.
MONTH S AVERAL12 DATLYBALANCE
\ y g e
LU ;
' ——&—————”
Average daily balances/6 months: h
Attachments ·
cc- File Q H -
Jim - A MIO?
` I r/;l0fO<1V

Case 1:08-cv-00073-GMS

Document 1

Filed 02/04/2008

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Case 1:08-cv-00073-GMS

Document 1

Filed 02/04/2008

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Case 1:08-cv-00073-GMS

Document 1-2

Filed 02/04/2008

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