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

Case 1 :06-cv-00368-SLR Document 13 Filed O2/06/2007 Page 1 of 2
AO 240 (Rev. IO/O3)
I DEI.,AWARE[Rev. MGS;
UNITED STATES DISTRICT COURT i
DISTRICT OF DELAWARE
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Plaint` f APPLICATION TO PROCEED _
( rv. Eg,. 0 Z ‘ WITHOUT PREPAYMENT OF
O _ € I /U.g\ l I- CL0 FEES AND AFFIDAVIT it
Defendant(s) _ * _ - I
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I, II xd 6 declare that I am the (check appropriate box)
Petitioner/Plaintiff/Movant U Other
in the above~entit1ed proceeding; that in support of my request to proceed without prepayment of fees or costs under I
28 USC §l9l5, 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. I y
S l
In support of this application, I answer the following quest enalty of perjury: i
l. Are you currently incarcerated? D Yes No (If "No" go to Question 2) l
-<;~·r·fT·t... V H _ · ` ’ i
If "YES" state the place of your incarceration _ ...i t- i... .. s III .I p
Inmate Identification Number (Required): y _ : _ 6 I
Ar ` em lo d at th ` stitution? Do you receive any ayment fro the i __P _\_:_ ¤- } nt . ...gt I ...rl
“”°“ ’° "“ p `
Attach o led er sheet om the institution o our incczrcemtio showin ot le l A
transactions
2. Are you currently employed? E Yes E 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 the answer is "NO" state the date of your last employment, the amount of your take-home
..... ga salary orw ges an pe `od gf n r _ ur last ernplo er. )
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3. In the past 12 twelve months have you receive any money from f the following sources?
a. Business, profession or other self-employment U Yes
b. Rent payments, interest or dividends El Yes N
c. Pensions, annuities or life insurance payments El Yes
d. Disability or workers compensation payments Ei Yes ` ,/·
e. Gifts or inheritances . El Yes f
f. Any other sources Ei Yes 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 :06-cv-00368-SLR Document 13 Filed O2/06/2007 Page 2 of 2
AO 240 Reverse {Rev. lD!03)
DELAWARE lRev, 4fUS
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4. Do you have any cash or checking or savings accounts? E1 Yes o
If "Yes" state the total amount $
5 . Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? _
E1 Yes l
It` "Yes" describe the property and state its value.
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; 6. List the persons who are dependent on you for support, state your relationship to each person and
‘ _ Wie te how much you contribute to their support, OR state NONE if applicable. ·
K3 T [U (MVK {
I declare under penalty of perjury that the above infomation is true and correct.
DATE Sl OF APPLICANT r
NOTE TO PRISONER: · A Prisoner seeking to proceed without prepayment of fees shall submit an
affidavit stating all assets. Inaddition, 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.