%AO 240 (Rev. 10/U3)
UNITED STATES DISTRICT COURT
FOR THE District of DELAWARE
GEORGE A. JAc1
FEES AND AFFIDAVIT { j
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_ Defendant °·`? g
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I, . (./— L ee L. _ I`. declare that I am the (check appropriate box)
K petitioner/plaintiff/movant [I other
in the above—entit1ed 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 thatI 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? >EYes I] No (If "No," go to Part 2)
If "Yes," state the place of your incarceration SUS SEX CORRECTIONAI. INSTITUTION
Are you employed at the institution? Y @*5 D0 you receive any payment from the institution? Xl E5 `
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 I;] No
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
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 of the following sources?
a. Business, profession or other self—emp1oyment I] Yes I] No
b. Rent payments, interest or dividends D Yes I] No
c. Pensions, annuities or life insurance payments III Yes III No
d. Disability or workers compensation payments I] Yes I] No
e. Gifts or inheritances I] Yes I] No
f. Any other sources EI Yes I] No
If the answer to any of the above is "Yes," describe, on the following page, each source of money and state the
amount received and what you expect you will continue to receive.
Case 1:O5—cv—OO823-SLR-LPS Document 27 Filed O1/06/2006 Page 2 of 2
AO 240 Reverse (Rev. 10/03)
4. D0 you have any cash or checking or savings accounts? E Yes I] No
If "Yes," state the total amount.
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or any other
thing of value? I] Yes III 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 contribute to their support.
I declare under penalty of perjury that the above information is true and correct.
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Date // Signature of Applicant
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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.
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