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

Case 1 :07—cv—00749-JJF Document 48 Filed 05/07/2008 Page 1 of 3
AO 240 (Rev. l0/O3)
DELAWAR.EtRev. 4/05
` UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Plaintiff APPLICATION TO PROCEED
i"j}F¤·< 3 , -·t\~ Cos-lei it WV.! A (2 5, 5 A Cc r WITHOUT PREPAYMENT OF
»~_, *¢;C¤ ‘ I .14*, QA _L yééd l ij ¢ s.} `
le *9** ye 4/,,5,; "£`»‘ » “°T“~ M M aw. an s ,»° i, R. WMU FEES AND AFFIDAVIT
L v A Dam . ""I "Ii f d t J, ZS ll**¤·¤·· ..
/ { C WW lh Cuff.? a%§§,)uc»¥°» U//Y`. Dy’¤'3f',¢··‘¤ I, Egimi ` [ ) O |g 3 declare thatl am the (check appropriate box)
El PetitionerfPlaintiff/Movant El Other
in the above—entitled proceeding; that in support of my request to proceed without pr ~• . · _ - -_;; z · A . . • .·
28 USC §l9l5, I declare that I am unable to pay the costs of these proceedings an that I am ‘ ttédg relief
sought in the complaint/petition/motion.
li/-lY ·~ 7 ZUU8
In support of this application, I answer the following questions under penalty of per · ry:
U/_ _ i"`”"""”**"*¤·-¤v•<., .
l. Are you currently incarcerated? E] Yes E No (lf "N0°` g0 ·• I .1 £* t i __.,;,,.,,
(“·‘ 5·7¤rr
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If "YES" state the place of your incarceration `
Inmate Identification Number (Required): [lg )ۤL;l (2 3 if
Are you 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 six months ’
transactions
2. Are you currently employed? D Yes EN)
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 from any ofthe following sources?
a. Business, profession or other self-employment Cl Yes J»2\/ No
b. Rent payments, interest or dividends El Yes D No
c. Pensions, annuities or life insurance payments ¤ Yes /_,l;1’ No
d. Disability or workers compensation payments U Yes ll2’" No
e. Gifts or inheritances E1 Yes Z1 No
f. Any other sources E1 Yes ,2l 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 :07—cv—00749-JJF Document 48 Filed 05/07/2008 Page 2 of 3
AO 240 Reverse (Rev. IO/03)
DELAWARE tkev. 4/05l
4. Do you have any cash or checking or savings accounts? El Yes M
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
El Yes ,2%
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.
OOO?
I declare under penalty of perjury that the above information is true and correct.
i f _ /
. DATE I SIGNATURE 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.

Case1:07—cv-00749-JJF Document 48 Filed 05/07/2008 Page30f3
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Case 1:07-cv-00749-JJF

Document 48

Filed 05/07/2008

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Case 1:07-cv-00749-JJF

Document 48

Filed 05/07/2008

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Case 1:07-cv-00749-JJF

Document 48

Filed 05/07/2008

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