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UNITED STATES DISTRICT COURT {lt?
DISTRICT OF DELAWARE lihf 22 Eli 9} El _
A 4 Piamnrr APPLICATION T0 PROCEED
_ V. WITHOUT PREPAYMENT OF
I/¢e>2LQg1 t ‘ - FEES AND AFFIDAVIT
l Defendant(s)
_ ` CASENUMBER: O§`·~ ‘§ 77 lz
1, (D ° declare that I am the (check appropriate box)
D Petitioner/Plair%`/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 §l915, I declare thatl 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 following questions under penalty of perjury:
l. Are you currently incarcerated? El Yes E No (If "No" go to Question 2) ’ ‘ l
If "YES" state the place of your incarceration `
. Inmate Identification Number (Required):_ A
Are you employed at the institution? l l Do you receive any payment from the institution?
Attach a ledger sheet from the institution of your incarceration showing at least the gas: six months ’
transactions
2. Are you currently employed? El 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
sal A or wages and ay period and the name and address of your last employer. 1 I
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3. D In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment D Yes No A `
b. Rent payments, interest or dividends D Yes No
c. Pensions, annuities or life insurance payments D Yes ¤ No
d. Disability or workers compensation payments D Yes f' No
e. Gifts or inheritances D Yes ji. No
f Any other sources _ .- [XL Yes D No
If the answer to any of the above is "YES" describe each source of money and state the amount q
J received AND what you expect you will continue to receiiéeéf I \qlp*]__ c 0 0/ ,l Z E A
l /
Case 1 :05—cv—00877-JJF Document 96 Filed 05/22/2008 Page 2 of 3
AO 240 Reverse (Rev. l0/03)
DELAWARESEW. 4/OS!
4. Do you have any cash or checking or savings accounts? E1 Yes §(No E
If "Yes" state the total amount S _
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property? .
I _ TQ-z<-M @@0,% EL Yes D 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 con `bute to their support, OR state NONE if applicable. ‘
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I declare under penalty of perjury that the above infomation is true and correct.
YW? NEO? (A MMSM/’
ATE SIGNATURE or APPLICANT I
NOTE T0 PRISONTER: ~ 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 theappropriate
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 ofeach account.
» Qqasge *p;Q5;,
2. List ALL income you have received from any source within the last 12 months and
identify the source if it is not listed on the table below. (Attach additional pages if
necessary.)
` How OFTEN
WHEN RECEIVED
SOURCE OF INCOME AMOUNT RECEIVED one time or re; at
Business, rofession or self-ern loyment
,R—=¤t ¤ one
i lnierssl __
ipividenas som stocks or bends
I Retirement or annuity payments (i.e. _ ,
Imdisabilit , social securi etc.) I lie!-Mg" H4 " ‘ r. - gif
Bank ·¢¤¢<¤¢¤¤¢ fafewsf _
l Othsv -
3. If you have a spouse, list ALL income YOUR SPOUSE has received from any source
within the last 12 months and identify the source if it is not listed on the table below.
(Attach additional pages if necessary.)
`i`i HOW OFTEN
g · WHEN RECEIVED
l SOURCE OF INCOME AMOUNT RECEIVED onetime orre ter)
Business, rofession or self-em lo ment
{Rem a ments
Interest E“]Ill_—
i Dividends from stocks or bonds
i Retirement or annuity payments (i.e.
i disability, social seeurit etc. l
Bank account interest
l Gifts
l_0th¤r¤ -—
2
All requests for information must be supplied, ifpossible. Failure to supply infomation may result in denial ofyour
application to proceed informa pauperis.
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