7 AO 240 [Rev. IDIGB) .
DEL.·\WAREtRev. ares;
C UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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’ riaamrr APPLICATION TO PROCEED
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Defendant(s)
D CASE NUMBER: °;¤_“.§_
I, lf) \§ L U Ei Lx QD K ic Q" declare that I am the (check [email protected]
El Petitione1 ovant El Other M O 8 __ 6 O .... Cp .
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in tl1e above—entitled proceeding; that in support of n1y request to proceed without prepayment of fees ogicostéiniider
28 USC §l9l5, I declare tl1at I am u11able to pay the costs of these proceedings and that I am entitledgltp
sought in the complaint/petition/motion. . --3
I11 support of this application, I answer the following questions under penalty of perjury;
l. Are you currently incarcerated? El Yes Mo 1 (If "No" go to Question 2)
If "YES" state the place of your incarceration . `
Inmate Identification Number (Required): iiii i S
Areiyou employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet Qorn the institution of your incarceration showing atleast the gast six months '
transactions I
. EI â€Â° _ , I __,_ Q · i·-IOO
2. Are you currently employed? Yes ’ No I r§~Q_@r 6 0 `@ (A5;- . is www-‘~rl’\
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 tl1e 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 tl1e past 12 twelve months have you received any money from any ofthe following soinces? S
a. Business, profession or other self-employment EI Yes |Zi__,_No
b. Rent payments, interest or dividends El Yes lh/No
c. Pensions, aimuities or life insurance payments El Yes EfL..No
d. Disability or workers compensation payments El Yes Qaljlc
e. Gifts or inheritances III Yes ttaffjg ...... .
£ Any other sources EI Yes dj} No
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.
_ Case 1 :08-cv—OOO60-SLR Document 1 Filed O1/28/2008 Page 2 of 2
A0 240 Reverse (Rev. EDFDE)
DELAWARElRev. 4/052
4. D0 you have any cash or checking or savings accounts? CLM-¥es ‘‘‘‘ ` ‘‘‘‘‘`‘ El No
lf "Yes" state the total amount S3 g--2 {O O
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
D Yes QHQ ,.., ,,,.,_ ,_
If "Yes" describe the property and state its value.
A 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.
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I declare under penalty of perjury that the above information is true and correct.
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· DATE 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.
Case 1:08-cv-00060-SLR
Document 1
Filed 01/28/2008
Page 1 of 2
Case 1:08-cv-00060-SLR
Document 1
Filed 01/28/2008
Page 2 of 2
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