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

, Case 1 :07-cv-00749-JJF Document 46 Filed 02/11/2008 Page 1 of 2
AO24U (Rev.10/U3]
DELAWARE gRev. ·l{D5l
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Piamttrr APPLICATION TO PROCEED
., V. WITHOUT PREPAYMENT OF
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FEES AND AFFIDAVIT
Defendant(s)
CASE NUMBER: Q7 g_ 1 qq
l, gy, Bn Eg, 1 Qamgg __ declare that l am the (check appropriate box)
D Petitioner ovant D 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 l am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the complaint/petition/motion.
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. . . . . . . ‘~%`?· Qts
In support of this application, I answer the following questigs under penalty of perjury:
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l. Are you currently incarcerated? El Yes No (If "No" go to Question 2) U? l§§§;@r¤..,,
lf "YES" state the place of your incarceration ,,,.
Inmate Identification Number (Required): _ 77
no
Are you employed at the institution? Do you receive any payment from the institution? Gi IT?
Attach a ledger sheet from the institution of your incarceration showing atleast the gas! six months '
transactions
2. Are you currently employed? D Yes ij No
a. lf 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 wm *5 q_“,_¥,,“
salary or wages and pay period and the name and address of your last employer.
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3. In the past l2 twelve months have you received any money from any ofthe following sources? -561, t,‘ri> ‘ 12;.55 `? HI,
as
a. Business, profession or other self-employment U Yes EK No Miihh l'l‘¢<•v¤·*5
b. Rent payments, interest or dividends El Yes E! No
c. Pensions, amtuities or life insurance payments El Yes E/No
d. Disability or workers compensation payments ¤ Yes No
e. Gifts or inheritances El Yes ?No A
f. Any other sources El Yes? ' 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.

G Case 1 :07-cv-00749-JJF Document 46 Filed 02/11/2008 n--Page 2 of 2
. 4
AO 240 Reverse (Rev. 10/ D3)
DELAWARE 1Rev. MGS!
4. Do you have any cash or checking or savings accounts? U Yes o
lf "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 li/161
lf "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.
J . c.
F. P
I declare under penalty of perjury that the above information is true and correct.
Q·ll· ¤‘l §)yt+\·t.M, G¤~·¤·~¤»bt·
DATE 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 balauces 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 1:07-cv-00749-JJF

Document 46

Filed 02/11/2008

Page 1 of 2

Case 1:07-cv-00749-JJF

Document 46

Filed 02/11/2008

Page 2 of 2