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

Case 1 :06-cv-00418-JJF Document 1 Filed 06/30/2006 Page 1 of 2
AO 240 (Rev. 10/ (B)
DELAWARE(Rev. 4/%)
UNITED STATES DISTRICT COURT
ISTRICT OF DELAWARE
as /@/( .
Plai APPLICATION TO PROCEED
V. / / WITHOUT PREPAYMENT OF
J FEES AND AF F IDAVIT
endant(
CASE NUMBER: ‘"‘
I, 6/J / declare that I am the (check appropriate box)
° ° Petitioner/Plaintitt7Movant ° ° 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.
In support of this application, I answer the follo {H , uestions under penalty of perjury:
l. Are you currently incarcerated? w ° °No (lf "No" go to Question 2)
**2
If "YES" state the place of your incarceration I
/’ " SE . . i
Inmate Identification Number (Require )· 5 . l I ‘
Are you employed at the institution'? you receive any payment from the institution? { I ‘
Attach a led er sheet om the institution 0 our i ceration showin at least the tsixi ¤_ p
2. Are you currently employed? ° ° Yes ° 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.
b. If tho 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 sou · '7
a. Business, profession or other self-employment · • Yes
b. Rent payments, interest or dividends • • Yes • (
c. Pensions, annuities or life insurance payments • • Yes I
d. Disability or workers compensation payments • · Yes { ;{4¤*‘€*·
e. Gifts or inlieritances · · Yes i' • •
£ Any other sources · • Yes · {7/ 0 ‘
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 :06-cv-00418-JJF Document 1 Filed 06/30/2006 Page 2 of 2
AO 240 Reverse (Rev. 10/(XJ)
DELAWARE QCBI
4. Do you have any cash or checking or savings accounts? • • Yes W
If "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles e • er
valuable property?
· · Yes 4
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.
1 declare under penalty of perjury that the above informati
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NOTE TO PRISONER: A Prisoner seeking to proceed without prepayment of fees shall submit an aftidavit
stating all assets. In addition, a prisoner must attach a statement certiiied 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 certified
statement of each account.