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

t Case 1 :07-cv-00749-JJF Document 20 Filed 12/27/2007 Page 1 of 3
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AO 240(Rev.1U/U3) , ............·--—-—-
DELAWARE {Rev. 4[GS] ? i E7 K)

UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE 2007
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a pnnarr APPLICATION ro rn tml
_ V. WITHOUT PREPAYMEN T OF
MEMLJOQQ FEES AND AFFIDAVIT
` Defendant(s)
1f- -
CASE NUMBER: . . .. . 2
· liaiuji Bq as U CI/{OO 7OUF
I, O /7 I declare that I am the (check appropriate box)
VK Petitioner ovant - • · Oil1€I` - . ~. I.
U ` . in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under e · l
I 28 USC §19l5, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief
sought in the tition/motion. · ` ‘
In support of application,_I_answer the following questionsunder penalty of perjury:0 " I _- I I l U I
1. Are you Q ._ ·_ __ . YNo (If "Nol' go to Question 2)
"YES" stateithe of incarceration. ‘ · Z d * i · i ‘ ‘ ‘ ’
Inmate Identification. Number (Required): 53 gf `
Are you employed at the institution? O Do you receive any payment from the institution? Af
Attach cx ledger sheet from the institution of your incarceration showing at least the past sbc mont/·1s’
transactions I
2. Are you currently employed? ° ° Yes ig


a. Ifthe 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. A} /,4
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. M /)g{
3. In the past l2_twelve months have you received any money from any of the-following
a. _, Business, professionor. other self-employinnt H 'F F- Yes U l l
b; ·-‘ - ’ e Rent payments, interest or dividends · · Yes ·/Qo
c. y Pensions, annuities or life insurance payments - * -· 7 • Yes ¤ - */Jo
F d. ° I Disability or workers compensation payments _• { Yes y _ _ ·~/ _ e. Gifts or inheritances · I l I · · Yes ·J)Jo _
f. Any other sources · · 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. lx//IQ

_ . Case 1 :07-cv-00749-JJF Document 20 Filed 12/27/2007 Page 2 of 3
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_ AO 240 Reverse [Rev.10,'D3) n
DEi.,AWARE$Rev. 4{DSI
4. Do you have any cash or checking or savings accounts? p · • Yes 1 ·/{ ‘ U I
in If "Yes" state the total amount $ U ` O l ‘ .
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles 0 ther r _ _
- valuable property? ` . fj/A - ·`
I • · Yes I · o
It` "Yes" describe the propeity 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.
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I declare under penalty of perjury that the above information is true and correct.
!9~"2·B'O g' st- jg éé _
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 appropriateinstitutional
officer showing all receipts, expenditures, and balances du ring the last six months in your institutional accounts. g
If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified
statement of each account.

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Case 1:07-cv-00749-JJF

Document 20

Filed 12/27/2007

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Case 1:07-cv-00749-JJF

Document 20

Filed 12/27/2007

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Case 1:07-cv-00749-JJF

Document 20

Filed 12/27/2007

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