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

Case 1:06-cv-00216-JJF Document 1 Filed O3/31/2006 Page 1 of 2
AO 240 (Rev. into?)
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UNITED STATES DISTRICT COURT
DISTRICT OF DELAWARE
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r- Piairrrirr APPLICATION TO PROCEED
· K _ . WITHOUT PREPAYMENT OF
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‘ · I G ·“K»\.¤ ·II¤-*·»·‘ FEES AND AF FIDAVIT
Defendant(s) ,
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I, A_."‘*- _, in Cx i ,/` ( _ _r lil; t» declare thatIam the (check appropriate box)
Petitioner/PIaintiff/Movant EI Other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §I9I5, 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.
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In support ofthis application, I answer the following questions under penalty of perjury; Egg`]
I. Are you currently incarcerated? III Yes Ekblo (If "No" go to Question 2)
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If "YES" state the place of your incarceration "'
Inmate Identification Number (Required):
Are you employed at the institution? Do you receive any payment from the institution?g-j
Attach a ledger sheet Qom the institution of your incarceration showing at least the gast six months ’
transactions _ _·
2. Are you currently employed? Yes El No
I
a. [fthe 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
salary or wages and pay period and the name and address ofyour last employer.
3. In the past I2 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment I3/gs D No
b. Rent payments, interest or dividends III Yes III N0
c. Pensions, annuities or life insurance payments III Yes C1 No
d. Disability or workers compensation payments E1 Yes E1 No
e. Gifts or inheritances 4 El Yes El No
f. Any otl r sou es _ _ es D No

Ifthe answer to any ofthe above is "YES" describe each source of money and state the amount
1 received AND what you expectyou willtcontingue to receive.
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Case 1:06-cv-00216-JJF Document 1 Filed O3/31/2006 Page 2 of 2
AO 240 Reverse (Rev IO/O3)
DELAWARE Rev. 4/OS! I
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4. Do you have any cash or checking or savings accounts? _ — Yes ll No /Wf/q Q (
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If "Yes" state the total amount $ ci
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? V
Q D No
If "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
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. \__
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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 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.
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