Free Motion for Miscellaneous Relief - District Court of Connecticut - Connecticut

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Case 3:03-cr—OO228-JCH Document 83-2 Filed O2/29/2008_ Page 1 of 2*) I. _
» United $tates District Court
Dtstrsct of Connecticut
» °§AO 240 (Rev. 10/03)
UNITED STATES DISTRICT COURTW-. <’T‘WV2¤~
2~io.r==rt D. abgra, Clerk
District of C ` • BY ·
United S tates of America . APPLICATION TO PROCEED I
Plaintiff WITHOUT PREPAYMENT OF
- V , . FEES AND AFFIDAVIT
Raymond Delvecchio
· CASE NUMBER: 3:03-MJ—OO183
Defendant _
I, Raymond Delvecchio I declare that I am the (check appropriate box)? _
Ki petitioner/plaintiff/movant I] other
I in the above·entitled proceeding; that in support of my request to proceed without prepayment of fees or costs
p under 28 USC §1915 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? Di Yes I _ I] No (If "No,” go to Part 2)
If "Yes," state the place of your incarceration LSCI A1 lenwood , White Deer , PA
Are you employed at the institution? YES Do you receive any payment from the institution? YES _
Attach a ledger sheet from the institution (s) of your incarceration showing at least the past six months’
transactions.
, 2. Are you currently employed? El Yes [Xl No
a. Ifthe 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.
I 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 [I Yes I1 No
b. Rent payments, interest or dividends El Yes [X No »
c. Pensions, annuities or life insurance payments I] Yes [X No ,
d. Disability or workers compensation payments EI Yes [X No ` .
e. Gifts or inheritances bit Yes El No , . ‘
- f. Any other sources El Yes · [X 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.

— I Case 3:03-cr—OO228-JCH Document 83-2 Filed O2/29/2008 Page 2 of 2
Ab 24(1fReverse (Rev. 10/Oil) _ .
if I generally receive gifts of $50tOO per month from my mother, I
»~ however, my mother is recently deceased.
4. Do you have any cash or checking or savings accounts? ii El Yes lX No I
If i‘Yes," state the total amount. ‘
5. Do you own any real estate, stocks, bonds, securitiesl other financial instruments, automobiles or any other I
thing of value? El Yes E No I ,
l If “Yes,’i describe the property and state its value. i l
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.
N/ A I ·
I declare under penalty of perjury that the above information is true and correct. ·
E,,,,,,,,,,,, 26 mg N /f 4%%%
_ Date · ' - A ‘ 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.