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

Case 1:05-cv—00572—SLR Document 1 Filed 08/05/2005 Page 1 of 2
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UNITED STATES DISTRICT C UF; ··· E U
DISTRICT OF DELAWA ’ 1
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Plaintiff APPLICATION T0 PROCEED
M V. WITHOUT PREPAYMENT OF
»,1= " FEES AND AFFIDAVIT
Defendant(s) _ r` _ “` I. q_ _ g
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I, declare that I am the (check appropriate box)
E/ Petitioner/Plaintiff/Movant Cl Other
in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under
28 USC §l9l 5, I declare that I am unable to pay the costs ofthese 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'? D Yes No (If "No" go to Question 2)
If "YES" state the place of your incarceration
Inmate Identiiication Number (Required):
Are you employed at the institution? Do you receive any payment from the institution?
Attach a ledger sheet @0112 the institution of your incarceration showing at least the gast six months '
transactions
2. Are you currently employed? El Yes [JN0
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
salary or wages .. d pay period and the name and address of your last employer.
3. In the past 12 twelve months A ave you received any money from any of the following sources?
a. Business, profession or other self—employment El Yes IH/No
b. Rent payments, interest or dividends E1 Yes lil/No
c. Pensions, annuities or life insurance payments El Yes V No
d. Disability or workers compensation payments |Zl· Yes I2/ No
e. Gifts or inheritances E1 Yes U/No
f. Any other sources El Yes E/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 1:05-cv—00572—SLR Document 1 Filed 08/05/2005 Page 2 of 2
AO 240 Reverse (Rev. 10/O3)
DELAW.»\RE!Rcv. 4/U5
4. D0 you have any cash or checking or savings accounts? E1 Yes
lf "Yes" state the total amount $
5. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other
valuable property?
Z' Yes E1 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.
l declare under penalty of perjury that the above information is true and correct.
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D TGE IG AT • 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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