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

Case 1 :08-cv—00034-SLB Documerw E 1/16/2008 Page 1 of 2
I L 1 AO 240 (Rev. IUJ'03) G _ R I L
DELAWARE Rev. 4fD5)
. Viitiil?. .
; Sililriiéi ti.5, !.§_{§%`i‘§i1€iI QQQSJIT
UNITED STATES DISTRICT COURT slr;. mst csi st;
DISTRICT OF DELAWARE . ` I
Elie? dsa 15 fail 9= 12
I I iowoi-hp) Li OJ I tit aig;5
Piamurr A APPLICATION TO PROCEED
V. WITHOUT PREPAYMENT OF
{ QF Q! at g rg Pg FEES AND AFFIDAVIT
Defendant(s)
` CASE NUMBER: rj 8 ~=· Q 3 A
I, I-_IT\ ~{"\u .. x_,a}`,i I )§ Q wv-..S declare that I am the (check appropriate box)
[Q2 Petitioner/Plaintiff/Movmrt 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 that I 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:
1. Are you currently incarcerated'? EI Yes mo (If "No" go to Question 2)
If "YES " state the place of your incarceration `
Inmate Identification Number (Required): L;] I |
Areyou employed at the institution? `1`~I0 Do you receive any payment from the institution? IQ O
Attach a ledg er sheet @0111 the institution of your incarceration showing at least the gast six: months'
transactions '
2. Are you currently employed? Yes EQ
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 "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 the past 12 twelve months have you received any money fro1n any of the following sources?
a. Business, profession or other self—employment El Yes
b. Rent payments, interest or dividends El Yes No
c, Pensions, annuities or life insurance payments El Yes E1/No I I
d. Disability or workers compensation payments EI Yes To
e. Gifts or inheritances El Yes Eye
f Any other sources _ El Yes 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.

Case 1 :08-cv—00034EL§‘ 1 Filed 01/16/2008 Page 2 of 2
AO 240 Reverse (Rev, IDIIJB] _ I i V W
DELAWARE Rev, 4.*0Sl
4. Do you have any cash or checking or savings accounts? Er Yes A
If "Yes" state the total amount $ l
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
El Yes E& .
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 a plicable.
l>.. Kerri'? carte; CL &u*·~l®f~} C Baer »j\¤iU"$ , N ML er i’l’@
, · x A c
p {CS Qhjk —§§.Uc,¤_, in `I (l¥‘*”\ ;urxe,\l;,Lg_, —i—¤_> c_,.>¤{‘i< CJ? `irl*\·=·S
O r\ l··w"\
r —lw*r\L., IO hl- w wl
i3' —l_li""\C¤¤\Jt‘lQ b¤5_l\\iC,v"·*‘-$ C Sdidd • XNKS V`)
YYWQJ {Y‘\»\ ·cJ"·l?€. .
A I declare under penalty of perjury that the above information is true and correct.
/4% ll K
DATE SIGNATURE OF APPLICANT ·
NOTE TO PRISONER: t A Prisoner seeking to proceed without prepayment of fees shall submit an
affidavit stating all assets. In·additi0n, a prisoner must attach a statement certified by the appropriate
institutional ofiicer 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 certiiied statement of each account.

Case 1:08-cv-00034-SLR

Document 1

Filed 01/16/2008

Page 1 of 2

Case 1:08-cv-00034-SLR

Document 1

Filed 01/16/2008

Page 2 of 2