Free Trust Fund Account Statement - District Court of Delaware - Delaware

r . Case 1 :05-cv-00306-JJF Document 5-2 Filed 06/23/2005 Page 1 of 3
’@s¤AO 240 (Rev. 10/{13) .
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UNITED STATES DISTRICT COURT ””*”"“"“"r·r*e·e
District of
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APPLICATION TO PROCEED
Plaintif WITHOUT PREPAYMENT OF
V FEES AND AFF IDAVIT
_ case NUMBER. a y e ` I
Defenda
I, declare that I am the (check appropriate box)
Lti petitioner/plaintiff/movant K] other
in the above—entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
under 28 USC §l9l5 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.
In support of this application, I answer the following questions under penalty of perjury:
1. Are you currently incarcerated? W Yes El No (If "No," go to Part 2)
if "Y<-=S-" sate the vim ¤f rw i¤¤¤r¤¤r¤¤i¤¤ 1 T /- z -:t‘ ·2¤ tr i s; *
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 rnonths’
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 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
n u t andnthg n e ndn ddress ofmyorur last em lo r. _ _ M
r· =-?‘ - ~e~ ; »
3. In the past 12 twelve months have you received any money from any of the following sources?
a. Business, profession or other self-employment El Yes No
b. Rent payments, interest or dividends El Yes No
c. Pensions, annuities or life insurance payments EI Yes * _A No
d. Disability or workers compensation payments El Yes No
e. Gifts or inheritances III Yes No
f. Any other sources I] Yes I ‘lll 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 1:05-cv—00306-JJF Document 5-2 Filed 06/23/2005 Page 2 of 3
AO 240 Reverse {Rev. l0/O3)
4. Do you have any cash or checking or savings accounts? El Yes E 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 U 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. M5 {MMS
I declare under penalty of perjury that the above information is true and correct.
oéf tit los Illghi 5, mghtggg.
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. lf you have
multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each
account.
it

T ‘@OB-JJF Document 5-2 Filed Pa9e3 of3
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