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

Case 1:06-cv—00787-Gl\/IS Document 1 Filed 12/22/2006 Page 1 of 2
AO 240 (Rev. l0/03)
DELAWARE Rev. 4/05
UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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Plaintif APPLICATION TO PROCEED
one Bia-:i.i,B ,q_r; V. . . WITHOUT PREPAYMENT OF
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Defendant(s)
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l, _ _,. · Q}, if ,. l. .,, {ji _ declare that I am the (check appropriate box)
M Petitioner/Plaintiff/Movant D Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l 5, 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 ofthis application, I answer the following questions under penalty of periury:
l. Are you currently incarcerated? El Yes ig/No (If "No" go to Question 2)
If "YES" state the place of your incarceration g_ ` _
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution? _
Attach a ledger sheet Qom the institution 0[your incarceration showing at least the past six months '
transactions
2. Are you currently employed? Yes El No
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. di Bit!-‘°li*¢*’¤ F*'·‘¤‘¢) D§l*"**~‘*‘~’=¥ M¤~`*gjj + 5¢‘¤=?·‘¤_§»i
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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 l2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self—employment El Yes No
b. Rent payments, interest or dividends D Yes at No
c. Pensions, annuities or life insurance payments E1 Yes ifi No
d. Disability or workers compensation payments E1 Yes }EI No
e. Gifts or inheritances E1 Yes No
f. Any other sources E1 Yes No
Ifthe 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 1:06-cv—00787-Gl\/IS Document 1 Filed 12/22/2006 Page 2 of 2
AO 240 Reverse (Rev. l0/O3)
DELAWARE Rev. 4/OS
4. Do you have any cash or checking or savings accounts? N Yes E1 No
If "Yes" state the total amount $ /}/7 So L*`¤·°/=i?··2/t‘*--
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? _ ,
E1 Yes % No
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.
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I declare under penalty of perjury that the above information is true and correct. I' 4 ·/
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D TE SI ATU P 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.