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

_ , Case 1 :06-cv-00212-GMS Document 8 Filed 06/23/2006 Page 1 of 3
%AO 240 [Rev. 10/03)
UNITED STATES DISTRICT COURT
District of
APPLICATION TO PROCEED
Plaintiff WITHOUT PREPAYMENT OF
V FEES AND AF FIDAVIT
case NUMBER: Ob" Q ll C C3 mg l
Defendant
<··"' _ ·
I, Baa Q 4 & *9**15 L [ IJ declare that I am the (check appropriate box) \
ymetitioner/plaintiff/movant I] other U
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC §1915 I declare that I am unable to pay the costs of these proceedings and thatl am entitled to the relief
sought in the complaint/petition/motion.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? I] Yes @@0 (If “No," go to Part 2)
If "Yes," state the place of your incarceration
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet from the institution (s) of your incarceration showing at least the past six months’
transactions.
2. Are you currently employed? I] Yes BTW rf i
a. If the answer is “Yes, " state the amount of your take-home salary or wages and pay period 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 l
and pay period and the name and address of your last employer. _ Q q
3. In the past 12 twelve months have you received any money from any of the following sou es?
a. Business, profession or other self-employment I] Yes E’l\lo @ gc .
b. Rent payments, interest or dividends E Yes E’No V) (Qin cg.; -1-; l.q ,
c. Pensions, annuities or life insurance payments E Yes §r‘No q `<§,§l Z -··- _ q
d. Disability or workers compensation payments EYes I] No Qi? E V"
e. Gifts or inheritances I] Yes J3 N o 3 QQ tg) Wl
f. Any other sources I] Yes Elblo Ig gg $ l
EEE ,
If the answer to any of the above is "Yes," describe, on the following page, each source of e s a e e
amount received and what you expect you will continue to receive. _ I

p ., Case 1:06-cv-00212—G|\/IS Document 8 Filed 06/23/2006 Page 2 of 3
AO 240 Reverse Rev. 10/03] ~
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4. Do you have any cash or checking or savings accounts? E/Yes III No
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If "Yes," state the total amount. 5 ( QQ T)
5. Do you own any real estate, stocks, bonds, s" curities, other financial instruments, automobiles or any other l
thing of value? El Yes @0
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. ;
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I declare under penalty of perjury that the above information is true and correct.
Date ' Signature of Applicant
NOTICE 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.

Case 1:06-cv-00212—G|\/IS Document 8 Filed 06/23/2006 Page 3 of 3
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